Membership Application

APPLICATION** FOR MEMBERSHIP IN IOWA ASSOCIATION
OF WORKERS' COMPENSATION LAWYERS, INC.

Name*

Phone Number*

Firm Address*

Fax Number

City*

State*

Zip Code*

Private Practice*

YesNo

Email Address*

Year admitted to practice?*

State*

Number of years involved in workers' compensation cases*

Percent of practice involved in workers' compensation cases?*

Number of cases filed or defended in last year?*

Number of Advisory Committee symposiums you have attended in the last five years?*

Number of IAWC Seminars you have attended?*

Have you given presentations on subjects involving workers' compensation?*

YesNo

If yes, complete the following:

Sponsor of Seminar?

Date

Topic

Additional information in support of your application:

References (including at least one current board member).*

Fee: $165.00/yearly DO NOT SEND MEMBERSHIP FEE WITH THIS APPLICATION UNTIL ACCEPTED AS A MEMBER.

Submitted by*

Date*

The information furnished as a part of this application will be held in confidence.

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