A GREAT OPPORTUNITY TO GROW YOUR BUSINESS Fill Out Form to be Considered for Verified Referrals Successful completion of this form will generate a contract to be digitally signed. Name*Phone Number*Email* Enter Email Confirm Email Law Firm*Website Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Area(s) of Law*States Licensed In*Counties Interested in Receiving Referrals*Check off which applies, if all, select all:* Hourly Retainer Flat fee Retainer Contingency Retainer Your business EIN #*It is understood that we will report all income received for referrals whether or not you send us a 1099. It is your duty to issue us a 1099 for your deduction purposes so that the IRS can properly give you the deduction.Have you ever been disciplined by an ethics board in any jurisdiction?*NoYesWe Cannot consider you for referrals. Thank you for your interest.Do you carry Malpractice Insurance?*NoYesWe Cannot consider you for referrals. Thank you for your interest.Would you like to refer clients through us in exchange for 33% of any commissions/referral fees earned*NoYes
