Location/Date of Boot Camp For Which You Are Applying:

First Name
Last Name
Organization
Street Address
Suite/Unit
City
State/Province
Zip/Postal Code
Work Phone
Cell Phone
E-mail
Website

Year Admitted to Practice Law:

Date admitted to NACA/NACBA or indicate JAG/Legal Aid/Non-Profit:

State/Federal Courts Where Admitted:

Current Practice Mix: (e.g., 80% Bankruptcy, 20% Family)

Undergraduate Major and Law School Graduated From:

How did you hear about the FDCPA Boot Camp:

Email
Postcard
Brochure
Former Boot Camper
Attorney
Word of Mouth
NACA Conference
Saw Speaker
Other

LEGAL AID/JAG/BUDDY ATTORNEYS ONLY: 

TO QUALIFY FOR THE DISCOUNT RATE YOU MUST BE EITHER A FULL-TIME LEGAL AID ATTORNEY, JAG ATTORNEY IN ANY BRANCH OF THE MILITARY, OR A BUDDY OF ANOTHER ATTORNEY WHO HAS ALREADY REGISTERED FOR THIS FDCPA BOOT CAMP AND EITHER A) WORK IN THE SAME FIRM AS YOUR BUDDY, OR, B) LIVE WITHIN 50 MILES OF YOUR BUDDY.  NOTE: Only One Buddy Rate per Regular Paid Attorney.

Your Organization, Law Firm, Employer, and Full Name of Your Buddy Attorney:

Your Position or Title:

Your City:

PLEASE READ CAREFULLY AND AGREE TO THIS CERTIFICATION BEFORE SIGNING:

I hereby apply for admission to the above FDCPA Boot Camp and enclose my nonrefundable fee payable to “Peter F. Barry” either by mailed check or paid via secure web page (Taxpayer ID 41-1868074). I understand that I will not receive a refund of any part of this fee unless my application is rejected. I have received the FDCPA Boot Camp brochure and have reviewed its contents as well as the no-refund cancellation policy and force majeure clause, both of which are incorporated herein by reference. I certify that I am a member of the National Association of Consumer Advocates (NACA), a member of the National Association of Consumer Bankruptcy Attorneys (NACBA), an attorney member of a Legal Services Corporation (LSC), an attorney member of a non-profit consumer rights organization, a JAG attorney, or a consumer bankruptcy attorney that performs no creditor work. (If I am a non-attorney law clerk, paralegal or staff member attendee, I certify that my supervising attorney is a member in good standing of NACA, NACBA, LSC, JAG, consumer bankruptcy firm or other qualifying non-profit consumer rights organization.) I am not currently a debt collector nor have I ever collected consumer debts in the past 5 years. If I have ever acted as a debt collector for consumer debts, or worked at a law firm that collected consumer debts within the past 5 years, I have attached a written and signed explanation of the same to this application. I certify that I have never defended, am not now defending, and do not ever intend to defend any kind of lawsuit brought by a consumer, including FDCPA lawsuit(s). Furthermore, I will not distribute, duplicate or use any materials, media, forms, or other information obtained by me arising out of this FDCPA Boot Camp, including the FDCPA Toolkit, without the express written permission, in advance, of Peter F. Barry, except as licensed for my professional use as more fully indicated in the informational brochure attached to this Application.  I also understand that I will be charged and will pay the full Regular Attorney rate if I am not a Legal Aid Attorney, JAG Attorney, or Buddy Attorney as listed above.

I Agree.  (Please E-Sign By Typing Your Full Name Here: (Ex: "s/Jane Q.  Public")

Date