Full Name
Date of Birth
Home Address
Street
City
State
ZIP
Phone
Email
Work Address
Street
City
State
ZIP
Phone
Fax
Email
Referral Information
Referred By
Education Information
List Academic Degree(s)
Include school(s) and year(s) of graduation
List Law Degree(s)
Include school(s) and year(s) of graduation
Professional Information
Name of Your Firm
Position
Number of Years in Practice
State Bar Number
State(s) Where Admitted
Date(s) of Admission
What percentage of your professional time are you now devoting to the defense of suits on behalf of individuals, insurance companies, and corporations?
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
References
Reference Number One
Provide name, address and telephone number
Reference Number Two
Provide name, address and telephone number
Applying for:
Full Membership Status
Associate Membership Status
I have read and do meet the membership eligibility requirements set forth at Article III, Section 2, of the Association By-Laws. The information I have furnished in this form is warranted to be true and correct. If accepted to membership, I agree to abide by the by-laws of this association.
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Arkansas Association of Defense Counsel
P.O. Box 10061
Russellville, AR 72812
voice 479-567-4597
info@arkansasdefensecounsel.com
Copyright 2001,2002 Arkansas Association of Defense Counsel.
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