Prefix

First Name*

Middle Name*

Last Name*

Name/Nickname you go by:

Birth Date (mm/dd/yyyy)*

Email Address (personal)

Home Address*

Home Number

Which address should we use for primary contact?*

Firm, Employer or Agency*

Employer's website

Size of firm/organization

Position*

Office Address*

Office Number*

Fax Number*

Email Address (work)*

Bar Status*

VA State Bar Number

Date Admitted (mm/dd/yyyy)

Legal Education

Referred by

I am not a member of the Virginia Bar; however, I am admitted to practice law in

Bar Number

Date Admitted (mm/dd/yyyy)

Name under which admitted (If different from above)

Membership (please Select one) *

Section Membership (check all that apply)

Bankruptcy Section ($25.00 dues)
Business Law Section ($30.00 dues)
Corporate Counsel Section ($25.00 dues)
Environmental & Energy Law Section ($25.00 dues)
Litigation Section ($25.00 dues)
Real Estate Section ($30.00 dues)

Membership Application