Attorney Enrollment
Missouri for Legal Expense Fund

For the purpose of registering with the Attorney General of Missouri for Legal Expense Fund Coverage (Section 105.711, RSMo Supp.) for practicing law without compensation through the {Name of pro bono agency}, a governmental agency or a nonprofit community social services center, the following information is provided.
 
Name:  _______________________________________________________________

Address:  _____________________________________________________________

City, State, Zip:  _______________________________________________________

Daytime phone: __________________________________________________________

Mo Bar Number: ___________________________________________________________

Place of employment, if any: __________________________________________________

Estimated number of hours per year of legal services provided without compensation are: ________

General area of law engaged in will be: __________________________________________

Records of clients represented through this program shall be maintained at:
[  ] {The name and address of the pro bono entity}
[  ]  At the address given above.

It is understood that:
(a)	I will not represent any client under this program if I have a preexisting attorney client relationship with the client under which fees have been collected or contracted for;
(b)	No fee will be charged, sought or accepted from the client for any representation or consultation  regardless of outcome;
(c)	I will not discriminate in providing legal services on the basis of race, sex, religion, national origin or ethnic background.

Signed ________________________________________________________

Witness for the governmental or charitable agency:  ___________________________________________________

Dated:  ___________________________________