Your name:       

Title:                  

Name of court:   

Street address:   

City:    State:    Zip:   

E-mail Address:   

Billing address:   

Phone (include area code):    Fax:   

Type of jurisdiction:   

Elected:    Appointed:   

Length of term:   

Term expires:   

Are you a member of a bar?:   Yes  No

If so, date admitted:    State:   

Annual dues $100* (group rates available)
Retired Judge $30

Spouse's name   

Referred by   
                 (not necessary for membership approval)