2009 Lawyer Referral Service Plan

2015-2016 LAWYER REFERRAL SERVICE PLAN

Lackawanna Bar Association will provide to the client the name and telephone number of one subscribing attorney.

The participating attorney shall pay to the Lackawanna Bar Association a fee of ninety-five ($95.00) dollars for five (5) panels per calendar year. Said calendar year begins on July 1, 2015 and ends June 30, 2016. Only the participating attorney is authorized to receive said referral and represent said client. The participating attorney must be an active member of the Lackawanna Bar Association. All attorneys must submit a copy of the declaration page of their current malpractice policy in order to participate.

□ New Member of Lawyer Referral □ Renewal of Current Membership (Please check renewed panels with an “X”)

Name: ______Mailing Address: ______Telephone: ( ) ______E-mail: ______

( ) Business & Tax Panel __Estate Administration __Post Conviction Relief __Intellectual Property __Estate Contesting __Franchise/Dealerships __Living Wills __Bankruptcy __Pensions __Collections/Defense of Claim __Simple Wills ( ) Family Law Panel __Contracts __Trust Busting __Adoption __Corporation Taxation __Trusts __Correction of Birth Certificate __Fictitious Name/Corporations __Elder Law __Custody __Liquor License __Guardianships __Divorce __Partnership __Incapacitated __Emancipation of a Minor __Patent __Grandparent’s Rights __Sale/Purchase ( ) Civil Litigation Panel __Name Change __Securities __Property Damage __Termination of Parental Rights __Trademarks __Miscellaneous Tort __Protection from Abuse/PFA __Corporation Tax __Federal Civil Court __Separation Agreement __Appellate/Appeals __Support ( ) Individual Rights Panel __Black Lung __Visitation __Age Discrimination __Defense Representation __Paternity/Confirmation of Paternity __Student Discrimination __Federal Worker’s Compensation __Dependency __U.S. Constitutional Law __Insurance __PA Constitutional Law __Labor Relations/Unions __ADA Act __Legal Malpractice Other Concentrations of Law: __Civil Rights __Defamation ______Commitments/Mental Health __Magistrate Appeals ______Consumer Protection __Magistrate Hearings ______Employment Discrimination __Medical Malpractice ______Federal Agys/Public Benefits __Motor Vehicle Accidents __Government Regulations __Negligence __Immigration/Naturalization __Product Liability Languages your office is fluent in __PHEAA Loan Default __Personal Injury speaking and writing: __Public Utilities Commission __Social Security ______School Law __Social Security Disability SSI ______Sexual Misconduct __Worker’s Compensation ______Sexual Harassment __Wrongful Death ______Special Education School Law __Environmental Law __State Agys/Public Benefits __Lemon Law By signing this certification I hereby __VA/Military Law __Unemployment Compensation acknowledge that I practice law in all __Eminent Domain __Wrongful Termination __Privacy __Bad Faith of the areas which I have checked off __Debtor Rights __Elder Abuse on this registration form as legal __Veterans Law/Veterans Appeals matters for which I will accept ( ) Real Estate Panel referrals. I also affirm that I am __Municipal Law __Foreclosure ( ) Criminal Law Panel legally competent, within the __Tenant v. Landlord __DUI meaning of Pennsylvania Disciplinary __Landlord v. Tenant __Expungement of Record Rule 1.1, to accept referrals for all __Preparation of Leases __Federal Cases the areas of law that I have checked __Real Estate Tax Problems __Felony __Real Estate Tax Litigation __Identity Theft off on this registration form as legal __Transfer of Property __Juvenile Law matters for which I will accept __Zoning Laws __Misdemeanor referrals. Furthermore, I __Deed Preparation __Private Criminal Complaints acknowledge that this is an __Eminent Domain __Summary __Oil & Gas Leasing __Traffic Violations individual member referral service ( ) Estate Law Panel __Underage Drinking and not a firm referral service. If for __Estate Planning __Appeals any reason, I cannot personally represent any person referred to me by the Lackawanna Bar Referral Service, I agree to refer that person back to the Bar Association and not to any other member of my firm or any other attorney.______