DATE:  ______________________

NAME:  _______________________________________________

*MEMBER OF OHIO BAR?  _____________   DATE OF ENTRANCE  ____________

LAW CLERK?  ____________________     TERM OF EMPLOYMENT  ___________

BUSINESS ADDRESS:   _____________________________________________

                                        _____________________________________________

                                        _____________________________________________

FIRM ASSOCIATION:  _________________________________________________

BUSINESS  PHONE:  _________________________________________________

E-MAIL ADDRESS:    _________________________________________________

HOME ADDRESS:      _________________________________________________

                                    __________________________________________________

                                    __________________________________________________

HOME PHONE:      _______________________________

*If you are a member of the Ohio Bar, employed by the City or County in any capacity, and also
in Private Practice, please list your office address and phone number below:

  __________________________________________________________

  __________________________________________________________

  ----------------------------------------------------------

Membership Dues:        1st year Bar Member  - Complimentary

                                     2nd - 49th year Bar Member - $25.00

                                     50th+ year Bar Member - Complimentary