Member Application

Full Name(Required)

Home Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Cell/Home Phone_(Required)

Email(Required)

Date of Birth

Is the practice of law your principal occupation?(Required)

Firm/Office(Required)

Firm/Office Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Firm/Office Phone(Required)

Firm/Office Fax #(Required)

Firm/Office Email(Required)

Ohio Attorney Registration Number(Required)

Year Admitted(Required)

Other State Bar Admissions with Year and Bar No.(Required)

Professional Affiliations, etc(Required)

Have you ever been the subject/respondent in a disciplinary procedure?(Required)

Yes

If so, please state the nature of the proceeding and its disposition and any related discipline opinion.

Applicant Signature(Required)

Date(Required)

This field is for validation purposes and should be left unchanged.

LAKE COUNTY BAR ASSOCIATION
25 North Park Place
Painesville, OH 44077
(440) 350-5800
E-mail: barassociation@lakecountyohio.gov
www.lakecountyohiobar.com