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Affiliate Attorney Response Card

Use this confidential form to apply to the Rutherford Institute's Affiliate Attorney Program. Once we receive your form, a member of our staff will contact you with more information.

"*" Required Field

First Name

Last Name

*Name :

*Firm / Company Name

*Company Address :

*City :

*State :

*ZIP :

Business Fax

*Business Phone :

*Email :

Law School

Graduation Date

List all states where you are licensed to practice.

List all courts in which you are admitted to appear.

What is your primary field of law practice?

List (in years) your litigation experience.

List (in years) your mediation experience.

Check all the ways in which you are willing to help the Institute.

	Litigation		Research		Speaking (conferences, churches, radio)
	Mediation		Writing for publication		Assist CLE/TRI attorney roundtables

Check the areas in which you are NOT able to assist the Institute.

	Free speech and religious liberty in the public arena, including schools.		Parental rights and family autonomy.		Human rights abuses including sexual harassment.
	Protecting churches, parochial and home schools from state intrusion.		Sanctity of life and/or right to peaceful protest.		Religious discrimination in employment.

May the Institute provide you with non Institute referrals in your areas of practice?

Yes No

List any cases or clients whom you have represented on behalf of the Institute in the past.