October 26, 2012-Boston, MA-Veterans Consortium Pro-Bono Program Training App & Contact Form Survey

*

1. First Name

First Name

*

2. Last Name

Last Name

(Note: This address will be used by the Program and by your client. Please do not enter a P.O. Box address.)

*

3. Contact Information

Contact Information Company:
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Email Address:

*

4. Telephone/Fax

Telephone/Fax Cell Phone
Personal Phone
Personal Fax
Work Telephone
Work Fax

5. Size of Organization/Firm

Size of Organization/Firm small (under 10)

medium (over 10 under 50)

large (over 50)

*

6. Have you previously applied for or attended a PBP training?

Have you previously applied for or attended a PBP training? Yes

No

7. Location and date of training you are interested in attending (if known)

Location and date of training you are interested in attending (if known)

8. How did you find out about the Pro Bono Program?

How did you find out about the Pro Bono Program?

9. Organization's/Firm's Pro-Bono Contact (if any):

Organization's/Firm's Pro-Bono Contact (if any):

*

10. Law school attended?

Law school attended?

*

11. Year of Graduation from law school? (write in none if not graduated law school)

Year of Graduation from law school? (write in none if not graduated law school)

*

12. How many years have you been licensed to practice law?

How many years have you been licensed to practice law?

*

13. Main areas of practice (check all that apply)?

Main areas of practice (check all that apply)? ADMINISTRATIVE

APPELLATE

ARBITRATION

CIVIL

COMMERCIAL/CORPORATE

CONTRACTS/GOVERNMENT CONTRACTS

CRIMINAL

ELDER LAW

FEDERAL LITIGATION

GENERAL

HEALTH

IMMIGRATION

INTELLECTUAL PROPERTY

INTERNATIONAL LAW

JAG/MILITARY

JUDGE

LABOR/EMPLOYMENT

LOBBYIST

MEDICAL MALPRACTICE

PERSONAL INJURY

SOCIAL SECURITY/DISABILITY

VETERANS/CAVC

WORKERS COMP

Other (please specify)

14. If you chose JAG/MILITARY as one of your practice areas, describe your practice areas/specialties within the JAG/military

If you chose JAG/MILITARY as one of your practice areas, describe your practice areas/specialties within the JAG/military

15. When (date) are you available to take a case (leave blank if no restriction)?

When (date) are you available to take a case (leave blank if no restriction)?

*

16. Bar status

Bar status

*

17. State in which you are Licensed (NA if not licensed)

State in which you are Licensed (NA if not licensed)

*

18. Bar Number (if your state does not issue bar numbers, enter NA)

Bar Number (if your state does not issue bar numbers, enter NA)

19. If you are licensed in more than one state or have ever been licensed in a state other than the one listed above, place the information in the box below

If you are licensed in more than one state or have ever been licensed in a state other than the one listed above, place the information in the box below

*

20. Have you ever been, or are you currently, the subject of a disciplinary complaint or been refused admission to practice, disbarred, suspended, reprimanded, sanctioned, or held in contempt by any court, administrative agency or regulatory body?

Have you ever been, or are you currently, the subject of a disciplinary complaint or been refused admission to practice, disbarred, suspended, reprimanded, sanctioned, or held in contempt by any court, administrative agency or regulatory body?

If yes, please explain

21. Additional languages spoken:

Additional languages spoken: Spanish

Other (please specify)

The Next Three Questions are Optional.

The Veterans Consortium Pro Bono Program requests demographic information from attorneys who volunteer for our Program. Any information that we collect is compiled for statistical purposes only in response to requirements of our federal grant. Your answers are optional. There is no penalty for declining to provide this information.

22. Your age:

Your age: 18-59 years of age

60 years of age and older

23. Ethnic background

Ethnic background Caucasian (white; non-Hispanic origin)

Black (non-Hispanic origin)

Hispanic Origin

Native American

Asian/Pacific Islander

Other/Mixed Race

Thank you for taking the time to consider these questions.

24. Gender

Gender Male

Female

25. Any additional comments?

Any additional comments?

October 26, 2012-Boston, MA-Veterans Consortium Pro-Bono Program Training App & Contact Form
Exit this survey

1. Default Section

October 26, 2012-Boston, MA-Veterans Consortium Pro-Bono Program Training App & Contact FormExit this survey

1. Default Section

October 26, 2012-Boston, MA-Veterans Consortium Pro-Bono Program Training App & Contact Form
Exit this survey