Application

Please Print

1. Name: _____________________________________________________________________

Address: ____________________________________________________________________

____________________________________________________________________

E-Mail: _____________________________________________________________________

Phone: ___________________________ Fax: ____________________________________

2. I would like to: ____ PROVIDE _____ RECEIVE Mentoring assistance.

3. FOR PROVIDERS:

a. In which setting do you practice?_____ Private Small Firm (1 - 6 lawyers) _____ Large Firm

(7+lawyers) _____ Corporate _____ In-House Counsel _____ Government (circle)

local state federal

b. Please indicate your total years in practice:

_____ Less than 1 year _____ 1 to 3 years _____ 3 to 5 years _____ more than 5 years

c. Please indicated specific areas of the law in which you have experience: ___________________________________________________________________________

___________________________________________________________________________

d. In what areas of law do you feel proficient in providing mentoring assistance?

___________________________________________________________________________

e. Legal malpractice insurance information:

Limits: per person ____________ Insurer ____________________________________________

Aggregate ______________ Policy No. ___________________ Effective Dates __________

4. FOR RECIPIENTS:

In what areas of law would you like to receive mentoring assistance?

___________________________________________________________________________

Please return your completed application to:

Essex County Bar Association

Shetland Office Park

45 Congress Street, Suite 4100

Salem, MA 01970

Phone: 978.741.7888

Fax: 978.741.1348