LRS Application

MEMBERSHIP APPLICATION

for the 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 E-mail: lindsay@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:

YESNO

ALL RIVERSIDE COUNTY COURTS:

YESNO

ALL ORANGE COUNTY COURTS:

YESNO

ALL LOS ANGELES COUNTY COURTS:

YESNO

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:

YESNO

13. DISABLED ACCESS?

YESNO

14. WILL YOU ACCEPT TELEPHONE CONSULTATIONS?

YESNO

15. WILL YOU MAKE HOME VISITS IN SPECIAL CIRCUMSTANCES?

YESNO

16. WILL YOU MAKE HOSPITAL VISITS IN SPECIAL CIRCUMSTANCES?

YESNO

17. WILL YOU MAKE JAIL VISITS?

YESNO

18. WHAT IS YOUR HOURLY RATE?: $

19. WHAT IS YOUR BASIC RETAINER FEE: $

20. WILL YOU ACCEPT PAYMENT PLANS?

YESNO

21. WILL YOU ACCEPT PRO BONO CASES?

YESNO

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. The 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 LAWB. CIVIL LITIGATIONC. COLLECTIONSD. CONSUMER LAWE. IMMIGRATIONF. LEMON LAWG. SELECTIVE SERVICE/MILITARY LAW

SOCIAL SECURITY

SSISSDI

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

FelonyMisdemeanor

B. BUSINESS LAW

Business LitigationNon-LitigationRetail Consumers and Credit

B. FAMILY LAW

Dissolutions & Related Matters

Adoptions

Step-parent adoptionsName Change

D. BANKRUPTCY

Personal InsolvenciesBusiness Insolvencies

E. JUVENILE LAW

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

F. PERSONAL INJURY & RELATED

Negligence

Professional Malpractice

AccountantsAttorneys

Medical Malpractice

Dental MalpracticePharmacologistPhysiciansPsychiatrist/Psychologists

Insurance Bad Faith

G: WORKERS’ COMPENSATION

Stress

H: REAL PROPERTY

Preparation of ContractsCondemnation LawConstruction LawLandlord/Tenant LitigationLitigationMechanic’s LiensZoning/Land Use

I: PROBATE, WILLS, TRUSTS & ESTATE PLANNING

Probate of EstatesWillsTrustsEstate PlanningConservatorshipGuardianshipElder LawMental Health Cases

J: PATENTS, COPYRIGHTS & TRADEMARKS

PatentsCopyrightsTrademarks

K: EMPLOYMENT

DiscriminationUnionsWrongful Termination of EmploymentUnemployment Board AppealsCivil Rights ActSexual Harassment

L: APPELLATE PRACTICE

CivilCriminalFamily LawOther:

Please state

M: TAXATION

FederalState

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

[text DATE

SIGNATURE
____________________

PLEASE USE THE SPACE PROVIDED BELOW FOR ANY ADDITIONAL INFORMATION REGARDING YOUR LAW PRACTICE THAT YOU FEEL WOULD BE USEFUL TO LRS IN REFERRING CLIENTS.

________________

________________

________________

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LAWYER REFERRAL SERVICE of the WESTERN SAN BERNARDINO COUNTY BAR ASSOCIATION

DISCIPLINARY STATUS DECLARATION FORM

This declaration is submitted to enable the Lawyer Referral Service of the Western San Bernardino County Bar Association to comply with the provisions of the California Civil Code §43.95 as amended effective January 1, 1981.

DECLARANT INFORMATION

NAME:
[text NAME_2]

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:

YESNO

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.