SurveyMonkey Powered Online Survey

Client Application Form

If you prefer to fax or mail this form, please print out and send to:

Volunteer Lawyers Service
260 Adelaide Street East
P.O. Box 102
Toronto, ON M5A 1N1
Phone: 416-977-4448 x 226
Fax: 416-977-6668

Please note that if you save your answers, your personal information will be kept on a secure server located in the United States. Your information will, therefore, be subject to the laws of that country that govern personal information. PBLO is NOT able to advise you about those laws. If you have any concerns about the security of your information, we encourage to read the privacy policy of the Volunteer Lawyers Service Interactive website and/or seek legal advice elsewhere.

Most fields below are mandatory. If you do not have a response, please indicate: N/A

1.Contact Information(Required.)

Your Name:

Organization Name:

Address 1:

Address 2:

City/Town:

Province:

Postal Code:

Email Address:

Phone Number:

2.Organization Information(Required.)

Name of Chair or President:

Name of Executive Director (or equivalent):

Number of full-time employees:

Number of part-time employees:

Number of volunteers:

Gross annual revenues:

Service catchment area(s):

Main funding source(s):

3.Is the organization incorporated?(Required.)

Yes

4.Is the organization a registered charity?(Required.)

Yes

If yes, indicate charitable reg. no.

5.What is your organization's mission statement?(Required.)

6.Describe in detail the programs and services your agency or initiative offers, or plans to offer in the future?(Required.)

7.What is the legal issue that you need help with?(Required.)

8.Provide detailed information on this legal issue and indicate how a lawyer might help you. For guidance on answering this question, see the 10-Point Legal Health Checkup on the VLS website at www.volunteerlawyers.org:(Required.)

9.Have you used Volunteer Lawyers Service in the past?(Required.)

Yes

10.How did you hear about Volunteer Lawyers Service?(Required.)

11.I/We hereby certify that the above information is true and correct. I/We I/we agree to provide the necessary support in working with a volunteer lawyer to ensure the success of the project. I/we certify that this agency is unable to afford fee-for-service legal support at this time and understand that disbursement costs are extra and will be paid by our agency.(Required.)

I/WE AGREE

12.I hereby authorize the Volunteer Lawyers Service, Pro Bono Law Ontario, to provide any of the information set out in this application (including any documents provided to the Volunteer Lawyers Service) to any person volunteering to assist Pro Bono Law Ontario with my case; any lawyer or law firm that Pro Bono Law Ontario believes may agree to act for me. I further authorize Pro Bono Law Ontario to retain copies of this application and any other document for record keeping purposes and to track the progress of my file.

I/We Agree

Eligibility is based on pre-established criteria and is subject to the approval process of Volunteer Lawyers Service. For more information on eligibility criteria, see www.volunteerlawyers.org.