Name:

Supreme Court ID No:

Telephone:

Firm Name:

Office Address:

City:

Zip Code:

County:

Email:

Date Admitted in Pennsylvania:

How long have you practiced law?

Foreign Languages:

Are there any felony charges or disciplinary proceedings pending against you in Pennsylvania or elsewhere?

Yes No

Areas of Pro Bono Service:

Are you willing to assist in services in your neighboring counties? Yes No

Are you accredited by the VBA and admitted to the Court of Veteran Appeals? Yes No

Are you a member of the PBA Military and Veterans' Affairs Committee? Yes No

If you are not a member, would you like to receive information on becoming a member? Yes No

Malpractice insurance is required of all participants.

Insurance Carrier:

Policy #:

Amount of Coverage:

Exp. Date:

I acknowledge that a requirement of my participation in the Pennsylvania Bar Association Lawyers Saluting Veterans program is to have lawyers' professional liability insurance coverage. Therefore, I agree to notify the Pennsylvania Bar Association within 10 days upon the cancellation of my lawyers' professional liability insurance policy.