Roster Application Form
Please submit the Roster Application by fax (1.866.382.7253) or email .
For technical issues, please email .
*Surname
*Given Name
*Middle Initial
*Firm Name
*GST Registration Number
*Are you GST Exempt?
*Year of Admission to the Alberta Bar
*Indicate if Student-at-Law
*Student-at-Law Principal
*Alberta Law Society Number
OFFICE ADDRESS
*Street / Box Number
*City
*Province
*Postal Code
*Phone Number
*Fax Number
*Email Address
BRANCH OFFICE DETAILS
If you have a branch office in any other location, please provide the details:
Street / Box Number
City
Province
Postal Code
Phone Number
Fax Number
ARE YOU A MEMBER OF ANY OTHER BAR? IF YES, PLEASE SPECIFY:
Where
Year Admitted
IN WHICH LANGUAGES, OTHER THAN ENGLISH, ARE YOU CONVERSANT? PLEASE LIST:
If you know American Sign Language, please indicate.
PRACTICE DETAILS
Please indicate below the type of files which you will accept as a Legal Aid Representative.
¨ Appeal – Criminal
¨ Appeal – Family/Civil
¨ Child Welfare
¨ Civil
¨ Criminal
¨ Duty Counsel
¨ Family
¨ Immigration
ADDITIONAL DETAILS / YES / NOI do not want to be placed on the general rotation roster but do want to be contacted when a legal aid client asks for me specifically.
Are you willing to travel more than twenty (20) kilometres to a courthouse?
Will your secretary/receptionist be allowed to accept referrals from Legal Aid Alberta on your behalf?
Are you willing to accept Change of Counsel files?
PLEASE PROVIDE ANY ADDITIONAL DETAILS REGARDING CASES YOU ARE WILLING OR UNWILLING TO TAKE.
ASSISTANT INFORMATION / YES / NO
Will your secretary/assistant be allowed to access your eBill account and billing information?
*I WOULD LIKE MY ASSISTANT TO BE THE RECIPIENT OF ALL CERTIFICATE RELATED INFORMATION. *Note – Please be aware that by selecting this option, all major communications will be submitted to the assistant’s email address, and NOT to the email address provided earlier in this form.
First Name: / Email Address:
Last Name: / Phone Number:
PRIVACY STATEMENT
Pursuant to the Personal Information Protection Act, Legal Aid Alberta is committed to protecting the personal information and privacy of all law firms and lawyers who accept legal aid certificates. Personal information of law firms and lawyers will not be released to any person, institution, association, or agency, unless it is deemed necessary for the provision of legal aid services or is legally required by Federal or Provincial laws.
DIRECT DEPOSIT AUTHORIZATION
Please ensure that all information is correct.
*Bank Name
*Bank Address
*Bank Transit Number
*Bank Number
*Account Number
*Type of Account
I UNDERSTAND AND AGREE THAT WHEN I ACCEPT APPOINTMENT TO ACT FOR A RECIPIENT OF LEGAL AID I WILL BE BOUND BY THE TERMS OF THE RETAINER CONTAINED ON THE LEGAL AID CERTIFICATE, FRONT AND BACK, AND BY THE LEGAL AID TARIFF AND THE LEGAL AID RULES, AS AMENDED FROM TIME TO TIME.
Signature: ______Dated: ______
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