Attorney Application Page One

NRBA Affiliate Member Application - Attorney

- Page One -

If you have not done so already:
Please read the NRBA Code of Ethics and NRBA Guidelines ,
prior to filling out this form.

Please read through the application and have the proper information before filling it out.
All information submitted will be verified!
Note: Please include area codes in your phone numbers.

** Required Entries

Personal and Company Information

**First Name	**Last Name

**Home Phone	**Firm

**Home Address	**Firm Address	**Business Phone	Extension

**Home City	**Firm City	Pager Number

	**Firm County	Cell Number

**Home State (two letter abbrev.)	**Firm State (two letter abbrev.)	Fax Number

**Home Zip	**Firm Zip	**E-mail Address

**Password Requested: (6-10 Characters)	Web Site Address (if any) (include complete URL)

**Verify Password: (Type it in again.)

Bar Associations/Affiliations

**Association	**Contact Name	**Contact Phone	**Bar Number

Association	Contact Name	Contact Phone	Bar Number

Association	Contact Name	Contact Phone	Bar Number

Errors & Omissions/Malpractice Insurance

**Company		**Policy Number

**Agent		**Minimum 100K?
		Yes No
**Agent Phone		**Effective Date

**Agent Fax		**Claims Pending?
		Yes No

Bank References - List financial institutions for whom you have performed work. A reference request will be sent to those you list below

Enter Contact Name, Company, Contact Phone, Contact Fax Number in each reference field.
At least one complete reference is required on this form.

**Person's Name	**Company	**Phone	**Fax

Person's Name	Company	Phone	Fax

Person's Name	Company	Phone	Fax

Person's Name	Company	Phone	Fax

Person's Name	Company	Phone	Fax