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BARRISTERS AIDS LEGAL SERVICES PROJECT/
HIV & AIDS LEGAL SERVICES ALLIANCE, INC. (HALSA)
APPLICATION AND AGREEMENT FOR PROJECT REFERRALS

PLEASE TYPE OR PRINT CLEARLY
State Bar No. _______________

Name______________________________________

Firm Name and Addrees_______________________________________________________________

__________________________________________________________________________________

Telephone (_____)________________  Alternate Telephone (_____)____________________________

Fax (_____)_________________  E-Mail Address__________________________________________

Foreign Languages Spoken (including American Sign Language)_________________________________

Primary area(s) of legal practice________________________________________________________

Since volunteers are sometimes called upon to travel to hospice facilites and client's homes, please indicate the areas to which you are willing to travel:
1.  San Fernando Valley
2.  East L.A._____ Downtown/Central L.A. _____
3.  San Gabriel Valley_____
4.  South Central L.A._____
5.  Southwest L.A._____

 7.   West L.A._____
8.   Wilshire District_____
9.   South Bay_____
10.  Anywhere in LA County_____
11.  Other_______________
12.  Other_______________

I agree to participate in this Project on a volunteer, noncompensatory basis. If I am unable to represent a client, I will refer the client back to the HIV & AIDS Legal services Alliance.

California Civil Code Section 43.95 requires us to disclose to the public the nature of any disciplinary action taken against an attorney who accepts referrals from our office. Have you ever been a party to a disciplinary proceeding by the State Bar of California?

Yes_____  No  If yes, what was the date?__________________________

Please describe in detail, on an attached sheet of paper, the nature of the disciplinary proceeding. Indicate whether any disciplinary action was taken as a result of the proceeding.

Panels and subpanels are listed on the reverse of the application.

HALSA PRO BONO REFERRAL PANELS AND SUBPANELS

Please circle the number and letter, if applicable, of the areas of law in which you will accept pro bono referrals from HALSA.

  1. Bankruptcy
    1. Debtor/Creditor
  2. Civil Litigation
  3. Conservatorship/Guardianship
  4. Criminal (advice only, no ongoing representation)
  5. Consumer
  6. Discrimination
    1. Civil Rights
    2. Employment
    3. Housing
    4. Insurance
    5. Medical
  7. Estate Planning
    1. Durable Powers of Attorney
    2. Durable Powers of Attorney for Healthcare
    3. Wills
    4. Trusts
    5. Probate
  8. Family Law
  9. Government Benefits
    1. Medicare/MediCal
    2. Social Security
  10. Healthcare/Patients' Rights
  11. Immigration
  12. Employment/Labor
    1. Employee Benefits
  13. Real Property
    1. Landlord - Tenant
    2. Litigation
  14. Tax
  15. Other:________________________________

In addition to accepting pro bono referrals, would you provide brief advice at legal clinics?
yes ________  No ________

____________________________________ ____________________________________
Signature Date Signed

If you have any questions, please telephone Laurie Aronoff at (213) 201-1492. Return the completed application to: Laurie Aronoff, Director of Volunteer Programs, HIV & AIDS Legal Services Alliance, 3550 Wilshire Blvd. Suite 750, Los Angeles, CA 90010. Or you can fax it to (213) 201-1594.     7/01