Home Address
Street Address:*
City:*
County:*
--None-- Allegheny, PA
Armstrong, PA
Atlantic, NJ
Bedford, PA
Berks, PA
Blair, PA
Bucks, PA
Burlington, NJ
Butler, PA
Camden, NJ
Cape May, NJ
Carbon, PA
Cecil, MD
Centre, PA
Chester, PA
Clearfield, PA
Columbia, PA
Cumberland, PA
Dauphin, PA
Delaware, PA
Erie, PA
Essex, NJ
Fayette, PA
Franklin, PA
Gloucester, NJ
Hartford, CT
Howard, MD
Hudson, NJ
Hunterdon, NJ
Huntingdon, PA
Kent, DE
Lackawanna, PA
Lancaster, PA
Lehigh, PA
Luzerne, PA
Lycoming, PA
Mercer, NJ
Middlesex, NJ
Mifflin, PA
Monmouth, NJ
Monroe, PA
Montgomery, PA
Montour, PA
Morris, NJ
Nassau, NY
New Castle, DE
Northampton, PA
Northumberland, PA
Perry, PA
Passaic, NJ
Philadelphia, PA
Pike, PA
Queens, NY
Salem, NJ
Schuylkill, PA
Snyder, PA
Somerset, PA
Susquehanna, PA
Union, PA,NJ
Wayne, PA
West Chester, NY
Westmoreland, PA
Wyoming, PA
York, PA
-Out of Region-
Zip:*
Primary Email:*
Primary Phone:*
Work Address:
Street Address:
City:
County:
--None-- Allegheny, PA
Armstrong, PA
Atlantic, NJ
Bedford, PA
Berks, PA
Blair, PA
Bucks, PA
Burlington, NJ
Butler, PA
Camden, NJ
Cape May, NJ
Carbon, PA
Cecil, MD
Centre, PA
Chester, PA
Clearfield, PA
Columbia, PA
Cumberland, PA
Dauphin, PA
Delaware, PA
Erie, PA
Essex, NJ
Fayette, PA
Franklin, PA
Gloucester, NJ
Hartford, CT
Howard, MD
Hudson, NJ
Hunterdon, NJ
Huntingdon, PA
Kent, DE
Lackawanna, PA
Lancaster, PA
Lehigh, PA
Luzerne, PA
Lycoming, PA
Mercer, NJ
Middlesex, NJ
Mifflin, PA
Monmouth, NJ
Monroe, PA
Montgomery, PA
Montour, PA
Morris, NJ
Nassau, NY
New Castle, DE
Northampton, PA
Northumberland, PA
Perry, PA
Passaic, NJ
Philadelphia, PA
Pike, PA
Queens, NY
Salem, NJ
Schuylkill, PA
Snyder, PA
Somerset, PA
Susquehanna, PA
Union, PA,NJ
Wayne, PA
West Chester, NY
Westmoreland, PA
Wyoming, PA
York, PA
-Out of Region-
Zip:
Secondary Phone:
Other Phone:
Website:
Fax:
Facebook:
Twitter:
Blog:
Background Information:
Business Category:*
--None-- Accommodation & Food Services Hotels & Traveler Accommodation
Administrative & Support & Waste Management & Remediation Services Office Administrative Services
Agriculture, Forestry, Fishing Oilseed & Grain Farming
Arts, Entertainment & Recreation Performing Arts Companies
Construction Land Subdivision & Land Development
Educational Services SchoolsElementary & Secondary
Finance & Insurance Central Bank, Monetary Authorities
Health Care & Social Assistance Physicians Offices
Information Newspaper, Periodical, Book, Newsletter & Database Publishers
Management of Companies & Enterprises Management of Companies & Enterprises
Manufacturing metal, foundry, structural materials, machines, engines, cars, boats
Manufacturing wood, chemicals, paper, pharmaceutical, paint, soap, nonmetals
Manufacturingfood, edible, fabric
Mining Oil & Gas Extraction
Other Services (except Public Administration) Automotive Repair & Maintenance
Professional, Scientific & Technical Services Legal Services
Public Administration Executive, Legislative & Other General Government Support
Real Estate & Rental & Leasing Real EstateLessors of
Retail Trade Dealersauto, boat, alcohol, grocery, equipment
Retail Trade Sporting Goods, Hobby & Toy, Musical Instrument Stores, books, ART DEALERS Antiques
Transportation & Warehousing Air TransportationScheduled
Transportation & Warehousing Postal Service
Utilities Electric Power Generation, Transmission & Distribution
Wholesale Trade Motor Vehicle, Motor Vehicle Parts & Supplies Wholesalers
Artistic Type:*
01 Individual Artist
02 Individual Non-Artist
03 Performing Group
04 Performing Group - College/University
05 Performing Group - Community
06 Performing Group - Youth
07 Performance Facility
08 Art Museum
09 Other Museum
10 Gallery/Exhibit Space
11 Cinema
12 Independent Press
13 Literary Magazine
14 Fair/Festival
15 Arts Center
16 Arts Council/Agency
17 Arts Service Organization
18 Union/Professional Association
19 School District
20 Parent-Teacher Organization
21 Elementary School
22 Middle School
23 Secondary School
24 Vocational/Technical School
25 Other School
26 College/University
27 Library
28 Historical Society
29 Humanities Council
30 Foundation
31 Corporation
32 Community Service Org
33 Correctional Institution
34 Health Care Facility
35 Religious Organization
36 Seniors' Center
37 Parks and Recreation
38 Government - Executive
39 Government - Judicial
40 Government - Legislative (House)
41 Government - Legislative (Senate)
42 Media - Periodical
43 Media - Daily Newspaper
44 Media - Weekly Newspaper
45 Media - Radio
46 Media - TV
47 Cultural Series Organization
48 School of the Arts
49 Arts Camp/Institute
50 Social Service Organization
51 Child Care Provider
99 None of the Above
01 Individual Artist
02 Individual Non-Artist
03 Performing Group
04 Performing Group - College/University
05 Performing Group - Community
06 Performing Group - Youth
07 Performance Facility
08 Art Museum
09 Other Museum
10 Gallery/Exhibit Space
11 Cinema
12 Independent Press
13 Literary Magazine
14 Fair/Festival
15 Arts Center
16 Arts Council/Agency
17 Arts Service Organization
18 Union/Professional Association
19 School District
20 Parent-Teacher Organization
21 Elementary School
22 Middle School
23 Secondary School
24 Vocational/Technical School
25 Other School
26 College/University
27 Library
28 Historical Society
29 Humanities Council
30 Foundation
31 Corporation
32 Community Service Org
33 Correctional Institution
34 Health Care Facility
35 Religious Organization
36 Seniors' Center
37 Parks and Recreation
38 Government - Executive
39 Government - Judicial
40 Government - Legislative (House)
41 Government - Legislative (Senate)
42 Media - Periodical
43 Media - Daily Newspaper
44 Media - Weekly Newspaper
45 Media - Radio
46 Media - TV
47 Cultural Series Organization
48 School of the Arts
49 Arts Camp/Institute
50 Social Service Organization
51 Child Care Provider
99 None of the Above
Primary Artistic Discipline:*
--None-- Crafts
Crafts: Clay
Crafts: Fiber
Crafts: Glass
Crafts: Leather
Crafts: Metal
Crafts: Mixed Media
Crafts: Paper
Crafts: Plastic
Crafts: Wood
Dance
Dance: Ballet
Dance: Ethnic/Jazz
Dance: Modern
Design Arts
Design Arts: Architecture
Design Arts: Fashion
Design Arts: Graphic
Design Arts: Industrial
Design Arts: Interior
Design Arts: Landscape Architecture
Design Arts: Urban/Metropolitan
Disciplines
Folk/Life/Traditional Arts
Folk/Traditional Crafts & Visual Arts
Folk/Traditional Dance
Folk/Traditional Music
Folk/Traditional Oral Traditions
Humanities storytelling
Interdisciplinary
Literature
Literature: Fiction
Literature: Non-Fiction
Literature: Playwriting
Literature: Poetry
Media Arts
Media Arts: Audio
Media Arts: Film
Media Arts: Technology/Experimental
Media Arts: Video
Multidisciplinary
Music
Music: Band
Music: Chamber
Music: Choral
Music: Ethnic
Music: Jazz
Music: New
Music: Orchestral
Music: Popular
Music: Solo/Recital
Musical Theatre
Opera
Photography
Theatre
Theatre: General
Theatre: Mime
Theatre: Puppet
Theatre: Theatre for Young Audiences
Visual Arts
Visual Arts: Experimental
Visual Arts: Graphics
Visual Arts: Painting
Visual Arts: Sculpture
NO ARTISTIC DISCIPLINE
Terms of Service: I hereby affirm that the information contained in this application, or attached to it, is correct, and to the best of my knowledge, complete. This questionnaire fully and accurately describes the problem for which this organization is requesting legal assistance. I understand that (1) PVLA and the Arts + Business Council for Greater Philadelphia (ABC) cannot guarantee that it will be able to refer my case to a volunteer attorney; (2) PVLA and ABC will not be responsible for the outcome of any referral which it makes; (3) I am free to select or not select any attorney to whom I am referred; (4) any attorney to whom I may be referred is free to accept or not accept the referral; (5) PVLA and ABC do not make any representations or guarantees about the quality of legal assistance which any attorneys to which I may be referred may provide; (6) I will be represented by the referred lawyer, not PVLA nor ABC; and (7) I agree to promptly notify PVLA and ABC if I no longer need the assistance of a volunteer.