MEMBERSHIP APPLICATION

 LAKE COUNTY BAR ASSOCIATION
 25 North Park Place
P. O. Box 490
Painesville, OH 44077

Phone: (440)350-5800 or (440)918-2180
FAX: (440) 350-2298
e-mail address: barassociation@lakecountyohio.gov

Full Name____________________________________________________________________________

Street Address________________________________________________________________________   

City & State___________________________________________________________Zip_____________

Home Phone_________________________________________________________________________

Is the practice of law your principal occupation? ____________________________________________

Firm/Office____________________________________________________________________________

Address______________________________________________________________________________

_______________________________________________________________Zip____________________

Phone_______________________________________ Fax #____________________________________

E-mail address_________________________________________________________________________

Attorney Registration Number ____________________________________________________________

Year admitted to Practice in Ohio__________________________________________________________

Other Bar Admissions and year___________________________________________________________

_____________________________________________________________________________________

Professional affiliations, etc._____________________________________________________________

_____________________________________________________________________________________

Have you ever been the subject/respondent in a disciplinary procedure?________________________

If so, please state the nature of the proceeding and its disposition______________________________

_____________________________________________________________________________________

Two personal and/or professional references:

Name ________________________________________________________________________________

Title/Position __________________________________________________________________________

Address ____________________________________________________Phone ____________________

Name ________________________________________________________________________________

Title/Position __________________________________________________________________________

Address ____________________________________________________Phone ____________________

____________________________________ ________________________________________
 Applicant Signature                                                              Date

________________________________________________ (OK)
Committee Member

__________________________________
Date