First Name: ^*

Last Name: ^*

Address 1: ^*

Address 2:

City: ^*

State: ^* - choose state - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip: ^*

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What is your state of principle practice? - choose state - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Does this state have a Family certification program? ^* Yes No

If so, are you certified by your state? ^* Yes No

(Applicants who are members of Florida Bar (Civil, Criminal & Family) must have first secured board certification through the Florida Bar. If you are not, please contact the Florida Bar)

Have you ever been denied or revoked certification by any state or national agency? ^* Yes No

Have you read the Standards for Recertification? ^* Yes No

Have you read the State Rules Regarding Stating Certification? ^* Yes No