Vermont Bar Association Lawyer Referral Service Application Form First Name Middle Initial Last Name Firm/Organization Address City State Phone # (000-000-0000) ZIP Code Fax # - (000-000-0000) E-Mail Address LOCATIONS: Addison Bennington Caledonia Chittenden Franklin Grand Isle Lamoille New Hampshire Orange Orleans Rutland Washington Windham Windsor Adoptions Arbitration Arts Law/Book Publishing Arts Law/ Entertainment Banking Law Banking Law/Commercial Copyrights Criminal/DWI Only Landlord/Tenant Landlord Only Public Health Real Estate Criminal/State Legal Malpractice Securities Criminal/Federal Domestic Mediation Mediation Domestic Social Security Disability SSI Education Law Medicaid Taxation Bankruptcy Elder Law Medical Malpractice Bankruptcy/Creditor Business/Partnerships Civil Rights Employment Entertainment Environmental Mental Health Military Municipal Law Civil Unions Estate Administration Non-Profit Collaborative Law Collaborative Family Law Collection Commercial Real Estate Construction Law Consumer Complaints Contracts Foreclosures Patents Taxation, Prop. Tax Appeals Tort & Negligence Trademarks Traffic Unemployment Compensation Wills, Trusts Guardianship Professional Licensing Workers Compensation Immigration Intellectual Property International Law Juvenile Labor Relations Zoning Other Licensed in another State(s): PLEASE ATTACH COPY OF DECLARATIONS PAGE FROM YOUR PROFESSIONAL LIABILITY POLICY I carry Professional Liability insurance in the amount of $ Name of Insurance Company I agree to hold the Vermont Bar Association harmless from claims by Vermont Bar Association Lawyer Referral Service Clients referred to me. I hereby certify competency in any area of law in which I am seeking referrals, subject to Rule 1.1 of the Rules of Professional Conduct. Date (00/00/00) Signature Individual Attorney - $60.00 Law Firm (5 lawyers or more) - $300.00 PAYMENT METHOD: Check enclosed (made payable to Vermont Bar Association) Credit Card Credit Card # - - - Exp. Date Cardholder Signature ___________________________________________________________________________ PLEASE PRINT COMPLETED FORM & MAIL WITH PAYMENT & DECLARATIONS PAGE TO: VERMONT BAR ASSOCIATION, PO BOX 100, MONTPELIER VT 05601-0100 American LegalNet, Inc. www.FormsWorkflow.com