WILSHIRE BAR ASSOCIATION

2010 DUES NOTICE AND APPLICATION FOR MEMBERSHIP

Please print and complete the form below and return it with your check,
made payable to the WILSHIRE BAR ASSOCIATION, to:

WILSHIRE BAR ASSOCIATION
c/o Law Offices of David B. Bloom
3699 Wilshire Boulevard, Tenth Floor
Los Angeles, CA 90010

Dues are $60.00 for those in practice for two (2) years or
more; $25.00 for those in practice less than two (2) years.

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NAME ________________________________________ STATE BAR NO. ______________

FIRM NAME OR JUDGESHIP LOCATION __________________________________________________________________

ADDRESS (PLEASE INCLUDE THE COURTROOM IF YOU ARE A JUDGE) ___________________________________________

_________________________________________________________________

CITY, STATE, ZIP CODE _______________________________________________________

PHONE NO. ____________________________ FAX NO. _____________________________

E-MAIL ______________________________________________________________________

GENERAL AREAS OF PRACTICE________________________________________________

SPECIALTIES AND/OR AREAS OF EXPERTISE ___________________________________

MEMBER OF THE LOS ANGELES COUNTY BAR ASSOCIATION? ___________________

I declare under penalty of perjury that I am a member in good standing of the
State Bar of California.

DATED: __________________

SIGNATURE ________________________________________