ST LOUIS-APRIL 13, 2011-VETERANS CONSORTIUM PROGRAM-TRAINING APPLICATION AND CONTACT FORM

1. Default Section

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1. First Name (Required.)

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2. Last Name (Required.)

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3. Contact Information (Required.)

Company: *

Address: *

Address 2:

City/Town: *

State: *

ZIP/Postal Code: *

Email Address: *

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4. Telephone/Fax (Required.)

Cell Phone

Personal Phone

Personal Fax

Work Telephone

Work Fax

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5. Size of Organization/Firm

small (under 10)

medium (over 10 under 50)

large (over 50)

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

Yes

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

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

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

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10. Law school attended? (Required.)

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

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

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13. 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)

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

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15. Bar status (Required.)

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

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

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18. 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

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19. Have you even 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? (Required.)

If yes, please explain

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20. Additional languages spoken:

Spanish

Other (please specify)

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* 1. First Name (Required.)

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* 2. Last Name (Required.)

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* 3. Contact Information (Required.)

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* 4. Telephone/Fax (Required.)

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* 5. Size of Organization/Firm

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* 6. Have you previously applied for or attended a PBP training? (Required.)

Question Title

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

Question Title

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

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

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* 10. Law school attended? (Required.)

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

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* 12. How many years have you been licensed to practice law? (Required.)

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

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

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* 15. Bar status (Required.)

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* 16. State in which you are Licensed (NA if not licensed) (Required.)

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

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* 18. 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

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* 19. Have you even 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? (Required.)

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* 20. Additional languages spoken:

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* 21. Any additional comments?

1. First Name (Required.)

2. Last Name (Required.)

3. Contact Information (Required.)

4. Telephone/Fax (Required.)

5. Size of Organization/Firm

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

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

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

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

10. Law school attended? (Required.)

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

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

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

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

15. Bar status (Required.)

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

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

18. 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

19. Have you even 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? (Required.)

20. Additional languages spoken:

21. Any additional comments?