Attorney Enrollment
(Name of Agency)

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 (AGENCY NAME), a nonprofit community social services center or state, local or federal government agency, 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 (AGENCY NAME & ADDRESS)
[  ]  At the address given above.

It is understood that:
(a)	I will not represent any client under this program if I have a pre-existing 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 (AGENCY)   ___________________________________________________

Dated:  ___________________________________