(909) 483-0548

LRS Application

MEMBERSHIP APPLICATION

for the LAWYER REFERRAL SERVICE of the Western San Bernardino County Bar Association

8291 Utica Avenue, Suite 102-Rancho Cucamonga, CA 91730
Phone: (909) 945-2980 ~ Fax: (909) 483-0553

E-mail: deva@wsbcba.org

1. SURNAME:

GIVEN NAME:

2. FIRM:

MEMBER/ASSOCIATE:

3. OFFICE ADDRESS:

SUITE

CITY

ZIP CODE

3a. Email:

4. TELEPHONE

FACSIMILE

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:
 YES NO

ALL RIVERSIDE COUNTY COURTS:
 YES NO

ALL ORANGE COUNTY COURTS:
 YES NO

ALL LOS ANGELES COUNTY COURTS:
 YES NO

10a. IF PRACTICE IS LIMITED TO CERTAIN COURTS, PLEASE NAME COURTS THAT YOU ARE WILLING TO APPEAR:

11. FOREIGN LANGUAGES SPOKEN: ATTY.:

STAFF

12. SIGN LANGUAGE:
 YES NO

13. DISABLED ACCESS?
 YES NO

14. WILL YOU ACCEPT TELEPHONE CONSULTATIONS?
 YES NO

15. WILL YOU MAKE HOME VISITS IN SPECIAL CIRCUMSTANCES?
 YES NO

16. WILL YOU MAKE HOSPITAL VISITS IN SPECIAL CIRCUMSTANCES?
 YES NO

17. WILL YOU MAKE JAIL VISITS?
 YES NO

18. WHAT IS YOUR HOURLY RATE?: $

19. WHAT IS YOUR BASIC RETAINER FEE: $

20. WILL YOU ACCEPT PAYMENT PLANS?
 YES NO

21. WILL YOU ACCEPT PRO BONO CASES?
 YES NO

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

SOCIAL SECURITY

 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

 Felony Misdemeanor

B. BUSINESS LAW

 Business Litigation Non-Litigation Retail Consumers and Credit

B. FAMILY LAW

 Dissolutions & Related Matters

Adoptions

 Step-parent adoptions Name Change

D. BANKRUPTCY

 Personal Insolvencies Business Insolvencies

E. JUVENILE LAW

 Dependency & Parental Rights (300 Series) Delinquency Cases (600 Series)

F. PERSONAL INJURY & RELATED

 Negligence

Professional Malpractice

 Accountants Attorneys

Medical Malpractice

 Dental Malpractice Pharmacologist Physicians Psychiatrist/Psychologists

 Insurance Bad Faith

G: WORKERS’ COMPENSATION

 Stress

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

K: EMPLOYMENT

 Discrimination Unions Wrongful Termination of Employment Unemployment Board Appeals Civil Rights Act Sexual Harassment

L: APPELLATE PRACTICE

 Civil Criminal Family Law Other:

Please state

M: TAXATION

 Federal State

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


Membership Panels



 I agree to provide pro bono services four (4) days per year.


or
 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

 Early AM

Please state

 NOON

 After 5:30 PM

 Latest appointment

Please state

 Saturdays

 Sundays

 OTHER

Please state

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.

DATE

FIRM:

ADDRESS

PHONE:

FAX:

E-MAIL:

DECLARATION

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?

CHECK ONE:

 YES NO

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.

Date:

Signature:

THIS FORM MUST BE SUBMITTED WITH THE APPLICATION FOR MEMBERSHIP.

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