Lawyer Collaboration with MARI Consultation

License*

Country of License*

US-State of License*

Canadian Province of license*

Other State/Province of License*

License Number*

Do you have any other license?*

Country of License-2*

US-State of License-2*

Canadian Province of license-2*

Other State/Province of License-2*

License-2 Number*

Title*

First Name*

Middle Initial

Last Name*

Suffix

Birth Date*

Gender *

Marital Status *

Specify Martial Status*

Language*

what is your Language*

Race*

Race type*

Home Address*

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Primary Phone (Cell or Home)*

Secondary Phone (Optional)

Personal Email Address*

Work Address

Street Address Address Line 2 City State ZIP Code

Work Phone

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Secondary Work Phone

Pager

Fax

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Fax

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Write about your interest and why you would like to collaborate with MARI Consultation:

Do you have any experience of medical law or similar knowledge? Please write in detail

Do/Did you have any medical law-related case that you would like to solve it through our expert team, in the meantime?

How and in which level, you are able to be involve and collaborate with MARI?

How is you free time?

Documents and Attachments

Attach a copy of all documents here you can add up to 20 files with JPEG, gif, PNG, PDF, Docx formats. size limitation per file is 5Mb

Drop files here or

Accepted file types: jpg, gif, png, pdf, , docx, Max. file size: 5 MB, Max. files: 20.

Any other people/business

Please refer us any other people/business who you would think that might be interested in working with us or may need consultation with us.

Other Information

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Their Role / why they might have information to contribute

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