Name:____________________________________________________________________
          (Last)                                               (First)                                (Middle)

TYPES OF PRACTICE ACCEPTABLE: (CHECK FIVE)

___1. Negligence, Personal Injury, Products Liability
___2. Domestic Relations, Divorce, Custody, Adoption
___3. Real Estate
___4. Wills, Trusts, Estates
___5. Collections, Contracts
___6. Consumer Complaints, 93A Claims
___7. Criminal
___8. Discrimination, Wrongful Termination.
___9. Guardians, Conservators, Name Change
___10. Business and Corporate Law
___11. Zoning, Variances, Planning Boards
___12. Bankruptcy
___13. Municipal Law
___14. Entertainment
___15. Malpractice (specify legal or medical)
___16. Patents, Copyrights, Trademarks
___17. Tax
___18. Immigration
___19. Labor
___20. Social Security, Unemployment, Administration Hearings
___21. Worker's Compensation
___22. Landlord-Tenant
___23. Other__________________________________________

Will you volunteer to attend our Wednesday evening Legal Clinic from 5-7 p.m. held at the Cambridge Superior Court?
 ___Yes ___No.

Do you agree to render a consultation to clients referred by MCBA for $25.00 per referral up to 1/2 hour?
 ___Yes ___No.

Would you accept one no-fee case per year?
 ___Yes ___No.

Do you carry malpractice insurance?
 ___Yes ___No. Please attach copy of same.

Signature ___________________________________________________

Date __________________________________________

Phone Number _________________________________

Fax Number ___________________________________

E-Mail ______________________________________________________________

Application Fee for Lawyer Referral Service is $50.00 per Calendar Year (in addition to $100.00 dues for Membership in the Association)

Fee remittance to MCBA is 15%