Attorney Enrollment Form

Name*

Firm/Employer Name*

Email Address*

Enter Email Confirm Email

Office Physical Address

Street Address Address Line 2 City State ZIP Code

Contact Phone Number*

Fax Number

Counties in which you will accept referrals:*

I am fluent in and willing to assist clients who speak the following languages:

I will accept 2 civil cases through the VLP in the area(s) of law indicated below:*

Privacy Statement

All information collected in this form will be used exclusively for the purpose of providing for indigent families in need of civil legal assistance. This information may be provided to a party outside the Alabama State Bar, but its use will be restricted exclusively to the purpose stated above. This information will not be sold or used for any marketing purposes by the ASB or any party to whom it is provided.

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