Clinic

Access to Justice Application Form

Attorney Name

Business Address

City

State

Zip

Business Phone

Business Email

Will offer Pro Bono

Yes

Will offer reduced rates to Clinic Referals
(under $75.00/hr fixed rate)

Yes

I can advise and/or mentor students in the following areas

I can accept referrals in:
(Use Ctrl key to select multiple items)

I am proficient in the following language(s):
(other than English)

I am licensed to practice in:

State

Federal

Tribal

I certify that I am a Malpractice Insurance Holder

Yes