Date of Admission ______________________________
State ID#______________________________________
Firm Name_____________________________________
______________________________________________
Address________________________________________
_______________________________________________Phone _________________________________________
FAX ___________________________________________
E-mail /Website____________________________________
________________________________________________
May we provide callers with your e-mail address
Yes ___ No_____
Is your office handicapped accessible Yes __ No____
Do you have evening hours ? Yes_____No________
Will you make home visits ?
Yes ______ No _______
Are you a trial attorney ?
Yes _______ No __________
Foreign Languages Spoken:___________________
______________________________________
Are you admitted to practice in any other state?________________
I am an attorney currently licensed in …………………………………………………..........................…
with License (or Bar) #…………………………………………………………………………………………
If yes , I hereby certify that :
I maintain the ongoing professional expertise
to handle referred matters competently, and I have no disciplinary
proceedings pending
against me; or, if there is a disciplinary proceeding pending before
either a district or department committee, I have attached an
explanation on a separate sheet.
-
If there is any change in this status, I agree to notify the service in
writing forthwith of same.
- I agree to serve persons referred to me in
accordance with the terms , which I have read.
Signed________________________________________
Date _________________________________________
Applications are subject to review before acceptance.
PLEASE ATTACH :
Payment: $500.00 bi-annually or $750.00 for the year
Or , Charge to MC/Visa/Amex
Card # …………………………………………………………………
Exp. Date………………................................................................
Print this page before completing information
Mail to :
7050 W. Palmetto Park Road
Suite 15-806
Boca Raton , Fl. 33433
or fax to us at 888 539 - 1010