Lawyer Referral Service Panelist Sign Up

1. Mr. Mrs. Ms.
2. *First Name
3. Middle Initial
4. *Last Name
5. *Firm / Business Name
6. *Mailing Address
8. *City
9. *State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
10. *Zip
11. *Office Phone
12. Fax
13. Cell Phone
14. *Email
15. I speak and am willing to accept clients who speak the following foreign languages.

1. Law School

   Enter law school name

2. Year Graduated
3. Other states and dates of admission
4. U.S. Patent Office Admission #

1. I am a member in good standing with the Indiana Supreme Court, and a member in good standing in every Bar to which I have been admitted. Yes   No
   
2. 
   I am currently a member of Indianapolis Bar Association. Yes   I have applied for membership   No
   

   required for participation

3. Professional Insurance Carrier
4. Professional Liability Insurance Policy #
5. Coverage Amount
6. Policy Expiration Date

1. *Professional Liability Policy

   Attach a copy of your professional liability insurance declaration page (.pdf format only)

2. *W9

   Attach a copy of your W9 (.pdf format only)

3. Mail/Fax Documents I will mail or fax these documents instead.

My principal office zip code is marked with a "1". I understand that I may select additional referral areas, and must be willing to travel to those location. Additional areas are marked with an "X".

1. Downtown (DT)
2. North (NO)
3. Northeast (NE)
4. Northwest (NW)
5. South (SO)
6. Southeast (SE)
7. Southwest (SW)
8. East (ES)
9. West (WS)
10. Boone County
11. Hamilton County
12. Hancock County
13. Hendricks County
14. Johnson County
15. Madison County
16. Morgan County
17. Shelby County

Of the major categories listed below, select a maximum of five to describe the types of cases for which you will accept referrals. Within the categories, please check all the types of cases you wish referred (LRS=Lawyer Referral Service, LAH=Legal Advice Hotline).

1. Education Law (EDU):
   LRS LAH Both
2. Environmental/OSHA (ENV):
   LRS LAH Both
3. Immigration (IMM):
   LRS LAH Both
4. Labor Law - Employee (LLE):
   LRS LAH Both
5. Labor Law - Management (LLM):
   LRS LAH Both
6. Medicaid (MED):
   LRS LAH Both
7. Military/Veteran's Affairs (MIV):
   LRS LAH Both
8. Motor Carrier (MTC):
   LRS LAH Both
9. Professional Licensing (PLB):
   LRS LAH Both
10. Sexual Harassment (SXH):
    LRS LAH Both
11. Social Security (SSI):
    LRS LAH Both
12. Unemployment Benefits (UEB):
    LRS LAH Both

1. Business Tax (BST):
   LRS LAH Both
2. Contracts (CNT):
   LRS LAH Both
3. Corporation/Partnerships (COP):
   LRS LAH Both
4. Sale of Business (SOB):
   LRS LAH Both
5. Securities (SEC):
   LRS LAH Both

1. Appeals (All courts) (CRA):
   LRS LAH Both
2. D.W.I. (DWI):
   LRS LAH Both
3. Felonies (CRM):
   LRS LAH Both
4. Juvenile (JVC):
   LRS LAH Both
5. License Suspension/Habitual Traffic Offender (LSS):
   LRS LAH Both
6. Misdemeanors (MIS):
   LRS LAH Both
7. Parole/Pardon/Probation/Expungement (PPP):
   LRS LAH Both
8. Traffic Violations (TRV):
   LRS LAH Both
9. Victims of Crime (VOC):
   LRS LAH Both

1. 1983 Et. Seq. (CVR):
   LRS LAH Both
2. Americans with Disabilities Act (ADA):
   LRS LAH Both
3. Employment Discrimination (EMP):
   LRS LAH Both
4. Housing (HUS):
   LRS LAH Both

1. Chapter 7 (CH7):
   LRS LAH Both
2. Chapter 11/Reorganizations (C11):
   LRS LAH Both
3. Chapter 13 (C13):
   LRS LAH Both
4. Collection Deferral (CLL):
   LRS LAH Both
5. Collection Harassment (CLH):
   LRS LAH Both
6. Consumer General (CNS):
   LRS LAH Both
7. Credit Reports (CRP):
   LRS LAH Both
8. Small Claims (SMC):
   LRS LAH Both

1. Adoption (ADP):
   LRS LAH Both
2. Custody Support (CUS):
   LRS LAH Both
3. Divorce/Family (DIV):
   LRS LAH Both
4. Juvenile (Noncriminal) (JUV):
   LRS LAH Both
5. Juvenile Emancipation (JEM):
   LRS LAH Both
6. Paternity (PTR):
   LRS LAH Both
7. Post Decree (PST):
   LRS LAH Both

1. Computer Law & Licensing (COM):
   LRS LAH Both
2. Copyright/Trademark (CTR):
   LRS LAH Both
3. Entertainment Law (ENT):
   LRS LAH Both
4. Patent (PAT):
   LRS LAH Both

1. Dental Malpractice (DMP)
   LRS LAH Both
2. General Civil Litigation (LIT)
   LRS LAH Both
3. Legal Malpractice (LGM)
   LRS LAH Both
4. Libel/Slander (LBS)
   LRS LAH Both
5. Medical Malpractice (MMP)
   LRS LAH Both
6. Nursing Home Negligence (NUR)
   LRS LAH Both
7. Personal Injury (PIP)
   LRS LAH Both
8. Product Liability (PLI)
   LRS LAH Both
9. Property Damage (PTD)
   LRS LAH Both
10. Public Authority Law (PAL)
    LRS LAH Both
11. Workman's Compensation (WRC)
    LRS LAH Both

1. Elder Law (EDL)
   LRS LAH Both
2. Estate Administration (EST)
   LRS LAH Both
3. Estate Planning (ESP)
   LRS LAH Both
4. Guardianships/Power of Attorney (GRD)
   LRS LAH Both
5. Name Change (NMC)
   LRS LAH Both
6. Personal Taxes (PIT)
   LRS LAH Both
7. Wills (WIL)
   LRS LAH Both

1. Commercial Real Estate (CRE):
   LRS LAH Both
2. Condemnations (CON):
   LRS LAH Both
3. Construction Problems (CSP):
   LRS LAH Both
4. Landlord (LAL):
   LRS LAH Both
5. Tenant (TEN):
   LRS LAH Both
6. Mechanics Liens (MCL):
   LRS LAH Both
7. Representation of Buyer (REB):
   LRS LAH Both
8. Representation of Seller (RES):
   LRS LAH Both
9. Zoning/Annexation (ZON):
   LRS LAH Both

1. Civil Appeals State (CVA):
   LRS LAH Both
2. Civil Appeals Federal (CVF):
   LRS LAH Both
3. Insurance Contracts/Pensions (INC):
   LRS LAH Both
4. International Law (INL):
   LRS LAH Both
5. Long-term Disability/ERISA (PEN):
   LRS LAH Both