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Essex County Bar Association
Mentor Program
Application
PLEASE PRINT
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, 36 Federal Street, Salem, MA 01970
Phone: (978) 741-7888 Fax: (978) 741-1348
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