NEWARK-OCTOBER 6-VETERANS CONSORTIUM PROGRAM-TRAINING APPLICATION AND CONTACT FORM

1. Default Section

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* 1. First Name

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* 2. Last Name

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* 3. Contact Information

Company: *

Address: *

Address 2:

City/Town: *

State: *

ZIP/Postal Code: *

Email Address:

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* 4. Telephone/Fax

Telephone Direct

Fax Direct

Telephone Firm

Fax Firm

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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?

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?

Write in none if not graduated law school.

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* 11. Year of Graduation from law school?

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

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* 13. Main area of practice?

(i.e., health, corporate, criminal, etc.)

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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

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

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

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* 18. If you are admitted to more than one Bar, place the information in the box below

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

If yes, please explain

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* 1. First Name

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* 2. Last Name

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* 3. Contact Information

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* 4. Telephone/Fax

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* 5. Size of Organization/Firm

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

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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?

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* 11. Year of Graduation from law school?

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

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* 13. Main area of practice?

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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

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

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

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* 18. If you are admitted to more than one Bar, place the information in the box below

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

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* 20. Any additional comments?