FIRST NAME * LAST NAME * FIRM * OFFICE ADDRESS * OFFICE PHONE NUMBER * E-MAIL * FIRM PRO BONO COORDINATOR (if applicable) NUMBER OF CASES YOU ARE WILLING TO ACCEPT PER YEAR PRO BONO CASES ALREADY ACCEPTED IN THIS CALENDAR YEAR AND SOURCE OF REFERRAL DOES YOUR PROFESSIONAL LIABILITY INSURANCE POLICY COVER PRO BONO CASES? Yes No BAR ADMISSION DATE ARE YOU IN GOOD STANDING WITH THE NC STATE BAR? Yes No CHECK ALL AREAS THAT INTEREST YOU Access to Health Care Bankruptcy (no assets) Business Law Civil Litigation Consumer Protection Domestic Violence Education Estate Planning Family Law Foreclosure Immigration Labor Landlord/Tenant Non-profit Real Estate Tax Veterans' Issues Other (please identify) IF YOU SELECTED OTHER, PLEASE SPECIFY CHECK ALL PROGRAMS IN WHICH YOU WOULD BE WILLING TO PARTICIPATE Training Programs (related to the substantive area of law) Mentoring Program - Mentor (designed to pair experienced private attorneys with inexperienced pro bono attorneys and legal services staff) Mentoring Program - Mentee (designed to pair experienced private attorneys with inexperienced pro bono attorneys and legal services staff) WOULD YOU BE WILLING TO TAKE A CASE FROM THE FOLLOWING LEGAL SERVICE PROVIDERS? Legal Aid of NC Legal Services of Southern Piedmont Council for Children's Rights (Custody advocacy program - attorneys must attend an all day training session) SelfServe Center at the Mecklenburg County Courthouse Safe Alliance International House COMMENTS