LAWYER REFERRAL SERVICE of the Western San Bernardino County Bar Association
8409 Utica Avenue, Rancho Cucamonga, CA 91730
Phone: (909) 945-2980 ~ Fax: (909) 483-0553
3. OFFICE ADDRESS:
5. BIRTH DATE
6. CALIFORNIA BAR ADMISSION DATE
7. CA STATE BAR NO.
8. BACKGROUND: LAW SCHOOL/YEAR OF GRADUATION
9. OTHER COURTS IN WHICH I AM ADMITTED/YEAR OF ADMISSION
9a. WHAT OTHER STATES ARE YOU LICENCED TO PRACTICE?
10. I AM AVAILABLE TO APPEAR IN:
ALL SAN BERNARDINO COUNTY COURTS:
ALL RIVERSIDE COUNTY COURTS:
ALL ORANGE COUNTY COURTS:
ALL LOS ANGELES COUNTY COURTS:
10a. IF PRACTICE IS LIMITED TO CERTAIN COURTS, PLEASE NAME COURTS THAT YOU ARE WILLING TO APPEAR:
11. FOREIGN LANGUAGES SPOKEN: ATTY.:
12. SIGN LANGUAGE:
13. DISABLED ACCESS?
14. WILL YOU ACCEPT TELEPHONE CONSULTATIONS?
15. WILL YOU MAKE HOME VISITS IN SPECIAL CIRCUMSTANCES?
16. WILL YOU MAKE HOSPITAL VISITS IN SPECIAL CIRCUMSTANCES?
17. WILL YOU MAKE JAIL VISITS?
18. WHAT IS YOUR HOURLY RATE?: $
19. WHAT IS YOUR BASIC RETAINER FEE: $
20. WILL YOU ACCEPT PAYMENT PLANS?
21. WILL YOU ACCEPT PRO BONO CASES?
22. I HAVE HAD SPECIAL, UNUSUAL OR EXTENSIVE EXPERIENCE IN THE FOLLOWING DIVISIONS OR PRACTICE OF LAW:
PLEASE READ EACH OF THE FOLLOWING BEFORE SIGNING APPLICATION:
1. I hereby certify that I am an active member in good standing of the State Bar of California and that I am engaged in the active practice of law, a substantial portion of my time and have a business office for such practice in the County of San Bernardino or the greater Inland Empire area.
2. A copy of the face sheet, or a copy of the binder, of my Errors and Omissions insurance policy in the minimum coverage amount of $100,000/$300,000, and showing no more than a $5,000. deductible is enclosed with my application.
3. I certify I have read and agree to abide by all the rules and policies of the Lawyer Referral Service (hereinafter “LRS”).
4. I agree to submit all fee disputes involving LRS clients to the Arbitration Committee of the San Bernardino County Bar Association and to be bound by its decisions and all rules and procedures of that Committee.
5. I agree to indemnify and hold harmless the Western San Bernardino County Bar Association, LRS, and its agents, from any and all claims, demands, actions, liability or loss, including but not limited to costs of defense including reasonable attorneys fees, which may arise from, or be incurred as a result of the all referrals of clients to me through the Lawyer Referral Service.
6. I agree to submit to current panel qualification procedures under Rule IV of the LRS Rules. Please note: Any applicant who is certified by the California Board of Legal Specialization as a specialist in a particular field by virtue of his or her certification shall be deemed qualified. The California Board of Legal Specialization certifies attorneys in Appellate, Bankruptcy, Criminal, Family Law, Immigration. Probate, Taxation and Workers’ Compensation law.
7. I understand that the staff of the LRS office, in compliance with Civil Code §43.95(a) and (b) shall have the duty to disclose to any client being referred to me the nature of any disciplinary actions which may have been taken against me, or by the State Bar of California.
8. I hereby certify that no disciplinary actions have been taken against me by the State Bar of California. (If any such actions have been taken, applicant should attach an explanation of the nature and disposition of said actions.)
9. As required by the Rules, I agree to participate in and/or pay appropriate assessment fees in regards to any such program(s) that are sponsored by the Western San Bernardino County Bar Association.
GENERAL PANEL MEMBERSHIP
ALL MUST SIGN UP FOR THE “GENERAL PANEL” MEMBERSHIP.
You may sign up for an unlimited number of the following sub-categories of the General Panel:
GENERAL PANEL MEMBERSHIP ($75.00 required)
Sub-Categories ($25.00 each):
A. ADMINISTRATIVE LAW B. CIVIL LITIGATION C. COLLECTIONS D. CONSUMER LAW E. IMMIGRATION F. LEMON LAW G. SELECTIVE SERVICE/MILITARY LAW
SSI SSDI SUBJECT MATTER PANEL MEMBERSHIP
10. I hereby apply for membership on the panels checked below and I declare that I qualify according to the standards set forth in the Rules:
With respect to any panels applied for which I do not meet the minimum standards, I attach hereto such information in support of my contention that I qualify for such panels by reason of substantial equivalent experience and/or education. (See attached Rules. Please provide additional expla-nation on separate sheet, if necessary.)
SUBJECT MATTER PANELS ARE AS FOLLOWS:
MAXIMUM OF THREE (3) PANELS; UNLIMITED SUB-PANELS WITHIN PANELS SELECTED.
($95.00/panel. No charge for sub-panels within selected panel.)
A. CRIMINAL LAW
B. BUSINESS LAW
Business Litigation Non-Litigation Retail Consumers and Credit
B. FAMILY LAW
Dissolutions & Related Matters
Step-parent adoptions Name Change
Personal Insolvencies Business Insolvencies
E. JUVENILE LAW
Dependency & Parental Rights (300 Series) Delinquency Cases (600 Series)
F. PERSONAL INJURY & RELATED
Dental Malpractice Pharmacologist Physicians Psychiatrist/Psychologists
Insurance Bad Faith
G: WORKERS’ COMPENSATION
H: REAL PROPERTY
Preparation of Contracts Condemnation Law Construction Law Landlord/Tenant Litigation Litigation Mechanic’s Liens Zoning/Land Use
I: PROBATE, WILLS, TRUSTS & ESTATE PLANNING
Probate of Estates Wills Trusts Estate Planning Conservatorship Guardianship Elder Law Mental Health Cases
J: PATENTS, COPYRIGHTS & TRADEMARKS
Patents Copyrights Trademarks
Discrimination Unions Wrongful Termination of Employment Unemployment Board Appeals Civil Rights Act Sexual Harassment
L: APPELLATE PRACTICE
Civil Criminal Family Law Other:
11. I am ENCLOSING the "ANNUAL" MEMBERSHIP FEES as follows:
$75.00 “GENERAL PANEL” (REQUIRED)
$25.00 per sub-category of the “GENERAL PANEL”.
$95.00 for each “SUBJECT MATTER PANEL”.
(No charge for sub-panels of the “Subject Matter” Panels.)
ASSESSMENT FEE: Pro Bono services may be required (See No. 9).
ASSESSMENT FEE section MUST be COMPLETED in order to process APPLICATION
I agree to provide pro bono services four (4) days per year.
I am enclosing assessment fee of $200.00.
ERRORS & OMISSIONS INSURANCE CARRIER:
(Forward a copy of the face page or binder for our files.)
Name of Company:
Date of Expiration:
APPOINTMENTS OUTSIDE REGULAR BUSINESS HOURS
After 5:30 PM
I DECLARE UNDER PENALTY OF PERJURY THAT THE INFORMATION CONTAINED HEREIN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND AGREE TO ABIDE BY ALL THE RULES OF THE LAWYER REFERRAL SERVICE AS SET FORTH HEREIN.
Have you ever been disciplined in this or in any other jurisdiction by a state or federal licensing agency when such disciplinary action became a matter of public record?
If you have been disciplined, by separate attachment fully disclose the nature of the disciplinary action taken, the name and location of the licensing agency involved, relevant date(s), and the ultimate disposition of the matter.
I agree to notify the Lawyer Referral Service of the Western San Bernardino County Bar Association of any disciplinary action taken against me while I am a panel member. I declare under penalty of perjury under the laws of the State of California, that the foregoing information, including any supplementary information, is true and correct to the best of my knowledge.
THIS FORM MUST BE SUBMITTED WITH THE APPLICATION FOR MEMBERSHIP.