ST LOUIS-APRIL 13, 2011-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

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)

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* 1. First Name

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* 2. Last Name

Question Title

* 3. Contact Information

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* 4. Telephone/Fax

Question Title

* 5. Size of Organization/Firm

Question Title

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

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?

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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. Any additional comments?