April 27, 2012 Miami, Florida-VETERANS CONSORTIUM PRO-BONO PROGRAM TRAINING APP & 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

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?

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?

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

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

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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

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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 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?

If yes, please explain

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* 20. 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.

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* 21. Your age:

18-59 years of age

60 years of age and older

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* 22. 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.

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* 23. Gender

Male

Female

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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? (write in none if not graduated law school)

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

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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

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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 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?

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* 20. Additional languages spoken:

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* 21. Your age:

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* 22. Ethnic background

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* 23. Gender

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* 24. Any additional comments?