Substantive Law Referral Categories
Signature and Acknowledgment
Problem Solver attorneys agree to provide a free thirty-minute consultation to children between
the ages of 13 and 17. Please check the referral categories under each panel for which you
would like to receive referrals. Complete the signature and acknowledgment section, and return
this form to the Oregon State Bar Referral & Information Services.
I am an active member of the Oregon State Bar in good standing and am not the subject of a formal
disciplinary proceeding. Please select one of the following:
o I maintain malpractice coverage with the Professional Liability Fund.
o I do not currently carry coverage with the Professional Liability Fund but will
participate but will participate in the Problem Solvers through the special policy
for OSB Certified Pro Bono Programs.
Signature _________________________________________________ Date_______________
(Print Name) ______________________________________________ Bar #
Address ______________________________________________________________________
City/State/Zip ______________________________________ Phone _____________________
Fax ________________________ Email ____________________________________________
I prefer to receive notices by o email o fax
o School Issues
o DMV/Traffic
o Consumer
o Juvenile Criminal Offenses
o Emancipation
o Family Law
o Domestic Violence
o Employment
o Immigration
o Other ____________________
FAX: 503.431.6444 MAIL: Oregon State Bar
Attn: RIS
PO Box 231935
Tigard, OR 97281-1935
12/2015
Return Form to:
Problem Solvers Program
Registration
Oregon State Bar Referral & Information Services
PO Box 231935, Tigard, OR 97281-1935
Voice: (503) 431-6408 or (800) 452-8260 ext. 408
Fax: (503) 431-6444 or Email: ris@osbar.org
