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Application and Agreement for Pro Bono Legal Professionals

(This information is confidential and will be used only at HALSA)

DATE: ___________________                                                                

CONTACT INFORMATION

Date of Birth: ______________                                               Sex: [  ] M   [  ] F   [  ] Transgender

Name: _______________________________________________________________________

Title: _________________________________________________________________________

Employer: _____________________________________________________________________

Home Address: __________________________________________________________________

City: ____________________________________  State: ______   ZIP Code: ________________

Home Phone: ________________________________________ Best Time to Call ___________

Business Phone: ______________________________________ Best Time to Call ___________

Cell Phone: __________________________________________ Best Time to Call ___________

May we leave a message at either of the above phone numbers?

[  ] Yes   [  ] No

Email Address:                                                 May we send email at this address?    [  ] Yes   [  ] No

VOLUNTEER INQUIRY

I am available: [  ] Day   [  ]Evenings   [  ] Weekends   [  ] Events  [  ] Special Projects

Education:

[  ] Undergraduate/Graduate Degree School ______________________________ Year _______

[  ] Completed certificate or other training Specify ______________________________________

Foreign languages spoken _________________________ Area of practice ____________________________

Applicable legal experience:

_________________________________________________________________________________________

_________________________________________________________________________________________

Other volunteer/community work:

_________________________________________________________________________________________

_________________________________________________________________________________________

I agree to participate with the HIV & AIDS Legal Services Alliance, Inc. on a volunteer, non-compensatory basis.