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Suffolk County Bar Association Pro Bono Project Attorney Registration Form

To be used by attorneys & others who wish to volunteer for the Pro Bono Project

Suffolk County Bar Association requests that you to complete the following form so that we may register you in the volunteer Pro Bono Project. Please note that the information contained herein is transmitted to us through a secure site. Fields marked with an "*" are required. If you have any questions you may contact us:
(631) 234-5511 (ext. 231), or E-Mail us at probono@scba.org
Date of Request *: Please use mm/dd/yy format
Name (full name [first & last])*:
Firm Name (if any)
E-mail Address*:
Address where we can contact you *:Street address:

City: State: Zip:

Work Phone (include area code)*:
Home Phone (include area code):
Cell Phone (include area code):
Fax (include area code):
Date admitted to the practice of law in New York State (required if attorney) Please use mm/dd/yy format
Department of Admission (required if attorney) First Dept.   Second Dept.   Third Dept.   Fourth Dept.
Attorney Certification (required if attorney or retired attorney)I certify that I am an attorney in good standing, admitted to practice in the State of New York -OR- I am a retired attorney who has practiced law in the State of New York for five of the last ten years.
Non Attorney VolunteersLaw School Graduate   Law Student   Paralegal   Other (describe)
LanguagesIn addition to English I speak the following languages:
Disabled accessibilityMy office is accessible to the disabled
My membership status is: *SCBA Attorney member                  SCBA Student member    Non-Member Attorney Non Member
I wish to volunteer in the following areas of law: (choose as many as you wish by clicking on each choice pressing the Ctrl key - scroll to see all choices)*
 
I cannot provide direct representation, but please sign me up for the following:

Mentor to Volunteer Attorneys   Research & Writing   Recruitment of Volunteers

I cannot volunteer my services, but wish to support the PBP with a tax-deductible contribution in the amount of (donations should be submitted via credit card payment below)

Method of payment:
Credit Card information:

Charge card type (choose one):

American Express (AMEX)              ,    Master Charge ,     Visa,    Discover

Account #             Expiration :  (please use mm/yy format)

I hereby authorize the Suffolk County Pro Bono Foundation to debit my credit card in the full amount of the donation listed above.

 

For security purposes, please type the two words that appear below:
    

 

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