INDIAN RIVER COUNTY BAR ASSOCIATION, INC.

                                          P.O. Box 896,  Vero Beach, FL 32961

                    Application for Membership

                                                                                                              Date: ________________________

1. Applicant's Name: ______________________________________________________________

Date Admitted to Florida Bar: __________________Fla.Bar No:___________________

2. Firm Name and Address: _______________________________________________________

            ________________________________________________________________________

Business Phone: ___________Fax Number:_____________E-Mail Address:__________________

3. Home Address: ___________________________________________________________________

        Home Phone: _______________                      Spouse's Name: ________________________

4. Other states to which you are admitted and dates of admission:

    ______________________________________________________________________________

5. Undergraduate Schools & Degrees: _______________________________________________

6. Graduate Schools & Degrees: ___________________________________________________

7. Law School: _________________________________________________________________

8. Other Bar Organizations/Associations in which you are/were a member:

American Bar Association: ___ Academy of Florida Trial Lawyers: _____ Others: ______________

_________________________________________________________________________________

9. If you previously practiced law, please provide the place or area and name and phone number of previous

    firm: ___________________________________________________________________________________

10. Please provide the name of any social organizations or civic organizations with which you are

    associated or are a member:

    _________________________________________________________________________________

_________________________________________________________________________________________

11. Areas of interest or committees on which you might like to serve:

      ____ Legal Aid      _____Courthouse/Judicial Liaison

     Other________________________________________     

12.  Pro Bono Areas of Interest

      _________________________________________________________________

13. Areas of practice:

     _________________________________________________________________________

      I  represent that I am in good standing with The Florida Bar. I acknowledge the information provided herein is true to the  best of my knowledge and belief. If admitted to the Indian River County Bar Association Inc., I agree to comply with all regulations and by-laws thereof, including timely payment of dues.

                   Signature of Applicant ________________________________