Name:

Supreme Court ID No:

Telephone:

Firm Name:

Office Address:

City:

Zip Code:

County:

E-mail Address:

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 Practice:

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

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

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

Insurance Carrier:

Policy #:

Amount of Coverage:

Exp. Date: