Online Lawyer Referral Service Membership Application

First Name*

Last Name*

Email Address to send LRS Referrals/Correspondence

Are you a FCBA Member?*

Yes No

Lawyer Referral Service (LRS) membership is conditioned upon FCBA membership. Applications for FCBA and LRS can be submitted together, (sepreate checks please).

Disciplined?*

Yes No

If yes, please explain briefly in a separate letter. Your correspondence should be addressed to the Lawyer Referral Service and will be treated as confidential.

All LRS members must complete a Preference Listing Form. The Steering Committee will review and determine categories listed, based on experience and competence. You will be notified if any of your requested categories are not approved. Contact LRS if you wish to make any inquiry or changes.

You may choose up to seven (7) areas in which you are experienced and competent from those listed below to receive referrals.

Courthouse Preferences:

Greenfield Orange Other

Additional Information

Insurance: LRS members are required to carry minimum Professional Liability coverage in the amount of $100,000/$300,000. Please aslo submit a declaration page of malpractice insurance to fcbar@franklincountybar.org.

Brokers Name & Address

Insurance Company

Amount of Liability Coverage

Policy Number

Expiration Date

Acceptance of Statement of Standards*

Yes

Statement of Standard can be viewed at https://franklincountybar.org/files/LRS_Statement_of_Standards.pdf

Submit Dues*

Yes $42

Acceptance of Waiver*

Yes

I hearby authorize the Board of Bar Overseers to release any and all information to the Lawyer Referral Service regarding any disciplinary proceedings that have been commenced against me by the Board of Oversears within five (5) years. This does not include complaints that have not resulted in the commencement of disciplinary proceedings. I understand that applicants who have been disciplined within the past five (5) years and not reviewed by the Lawyer Referral Service Committee will not be accepted until a satisfactory review by the Committee. Current panelists who are disciplined will be suspended untill a favorable review by the Lawyer Referral Service Committee. This release shall expire one (1) year from the date listed below.

Acceptance of Rules*

Yes

LRS Rules: I hereby acknowledge that I have reviewed the LRS Statement of Standards and Rules. I agree to comply with the Rules and affirm that the statements and information on file with the LRS are true and complete.

Competence: I hereby certify that in accordance with section X of the LRS Statement of Standards, I am competent and experienced in the referral areas selected on the application. I agree to hold the Franklin County Bar Association harmless from any and all claims arising out of representation of clients referred by LRS.

Insurance: I acknowledge that I am required to carry and therefore do carry minimum Professional Liability coverage of $100,000/$300,000. A copy of the current declaration page, with expiration date, has been submitted with the LRS application. I further agree to notify LRS immediately if this policy is terminated or coverage is reduced during the period of the LRS application.

Disciplinary Action: I acknowledge that I am a member in good standing of the Bar. I have never been disciplined by the Board of Bar Overseers or any other disciplinary authority in this or other jurisdiction. I have complied with the registration requirements of the Board of Bar Overseers. If there has been such discipline, a letter is submitted with my application.

Fees: I will abide by SJC Rule 3:07 on the use of written fee agreements. (Please see section 4.3 d. of the Statement of Standards regarding resolutions of fee disputes.) I will speak with each referred party either by phone or in person to determine whether I will take the case and, if so, what my fee will be, how I will bill for my services, and what the scope of my representation will be.

Dues: I have remitted my $40 non-refundable Lawyer Referral Service dues.

Referral Fee: I acknowledge an obligation to remit to the LRS ten percent (10%) of the total collected fees for cases $100 and over which will be sent within thirty (30) days of client payment.

Reporting: I acknowledge that I must return all report forms as requested.

-If applying for the first time, please also send a resume and references to fcbar@franklincountybar.org.

Signature*

Your Monday Color*

You will be asked to submit any payments on the next page.

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