<p> JEFFERSONJEFFERSON COUNTYCOUNTY BARBAR ASSOCIATIONASSOCIATION MEMBERSHIPMEMBERSHIP APPLICATIONAPPLICATION 2012-20132012-2013 1001 Pearl, Ste. 202 ▪ Beaumont, TX 77701 ▪ 409-835-8647▪ 409-835-8778 FAX ▪ www.jcba.org ▪ [email protected]</p><p>Every membership request/renewal must provide an application. If you are over 70 and exempt from Bar dues, please complete & return the application. NAME & ADDRESS (please print)</p><p>Name______</p><p>Firm ______Email Address______</p><p>Work Address______City ______State ______Zip ______</p><p>Phone ( ) ______Fax ( ) ______Bar Card # ______DOB _____ / _____ / ______</p><p>Home Address ______City______State______Zip______</p><p>Home Phone ( )______Spouse ______Website Address______</p><p>Cell Phone (optional) ______Male □ Female □ Please tell us how you would like to be contacted □ Email □ Fax</p><p>How would you like to receive the Jefferson County Bar Journal publication? □ Printed publication via Mail □ PDF file via email?</p><p>PRACTICE SETTING</p><p>Judge □ Federal □ State □ Probate Attor ney □ Private Practice □ Government Position □ Corporate □ Partner, Shareholder or Associate in law practice □ Professor □ Retired □ Law Office Staff Other □ Non-law related □ Law Student □ Other ______</p><p>CATEGORY SETTING</p><p>In which area/s of law do you primarily practice? ______In which area/s are you Board Certified? ______</p><p>Other state(s) licensed to practice ______Language(s) spoken ______</p><p>MEMBERSHIP CATEGORY Please check appropriate category □ JCBA Membership $ 100.00 ______□ JCBA Senior Membership (70 yrs or over) $ N/A ______□ JCYLA Membership* (in practice less than 5 years and/or 36 years of age or younger) $ 75.00 ______* All JCYLA Attorneys are granted JCBA membership automatically SECTION MEMBERSHIP *must be a JCBA/JCYLA member to join any section □ Family Law Section $ 30.00 ______□ Criminal Defense Section $ 30.00 ______</p><p>Total Amount Due $ ______SUBMITTING PAYMENT Please make checks payable to the Jefferson County Bar Association Retur n application and payment to 1001 Pearl Street, Ste. 202 / Beaumont, Texas 77701 Thank you for your suppor t! Office Use Only Amt$ ______Cash□ Check# ______CC/WS □ Received ______Renewal □ New Member □ Database □ Website □ Initials ______</p>