VIRGIN ISLANDS BAR ASSOCIATION
     GRIEVANCE FORM
     
     PART A: INFORMATION ABOUT YOU - PLEASE KEEP CURRENT
     It is necessary in order to timely process your grievance that all information be typed or printed legibly.
     
     IF BLANKS ARE LEFT ON THIS FORM OR ALL QUESTIONS ARE NOT ANSWERED THE PROCESSING OF YOUR GRIEVANCE MAY BE DELAYED.
     
     1.
     NAME:
     LAST FIRST MIDDLE
     
     2.
     MAILING ADDRESS:
     CITY: STATE: ZIP: PHONE: ( )
     3.
     EMPLOYER:
     4.
     WORK ADDRESS:
     
     WORK PHONE: ( )
     
     5.
     MAY WE CONTACT YOU AT YOUR EMPLOYMENT? YES NO
     
     6.
     DRIVERS LICENSE # DATE OF BIRTH
     
     7. NAME, ADDRESS AND PHONE NUMBER of person not in your household who can always reach you.
     NAME: ADDRESS:
     PHONE: ( )
     
     8.
     Are you represented by an attorney now? If so, please provide:
     
     NAME: ADDRESS:
     PHONE: ( )
     
     9.
     How did you hear about the grievance process: (Check One)
     ___ Bar Office ___Attorney in Complaint
     ___ Another Attorney ____Website ___ Other
     
     10.
     Do you understand and write in the English language? Yes__ No __
     If no, what is your primary language?
     Who helped you prepare this form?
     Will they be available to translate future correspondence during this process?
     Yes__ No __
     
     11. Please let us know as soon as possible if you have a special need or disability that will require a reasonable accommodation, and let us know what accommodation you are requesting.
     
     IF ANY OF THE ABOVE INFORMATION SHOULD CHANGE IT IS NECESSARY THAT YOU ADVISE THE VIRGIN ISLANDS BAR ASSOCIATION IN WRITING IMMEDIATELY. PLEASE DO NOT WRITE ON THE BACK OF ANY PAGES OF THIS COMPLAINT FORM. USE ADDITIONAL PAPER IF NECESSARY. PLEASE WRITE ON ONE SIDE ONLY.
     
     
     PART B: INFORMATION ABOUT ATTORNEY
     COMPLAINTS ARE NOT ACCEPTED AGAINST LAW FIRMS AND MUST SPECIFICALLY NAME THE ATTORNEY AGAINST WHOM YOU ARE COMPLAINING. A SEPARATE GRIEVANCE FORM MUST BE COMPLETED FOR EACH ATTORNEY AGAINST WHOM YOU ARE COMPLAINING.
     
     1. ATTORNEY NAME:
     2. ADDRESS:
     
     CITY: STATE: ZIP:
     
     OFFICE PHONE: ( )
     HOME PHONE: ( )
     
     3.Date attorney hired or appointed?:
     
     4. What did you hire the attorney to do?:
      .
     
     5.Where did the activity you are complaining about occur? Island:
     
     IF BLANKS ARE LEFT ON THIS FORM OR ALL QUESTIONS ARE NOT ANSWERED THE PROCESSING OF YOUR GRIEVANCE MAY BE DELAYED.
     
     PLEASE BE ADVISED THAT RULE 16 OF THE VIRGIN ISLANDS RULES FOR LAWYER DISCIPLINARY ENFORCEMENT REQUIRE THAT ALL INFORMATION COMING TO THE ATTENTION OF THE INVESTIGATORY PANEL CAN BE MADE PUBLIC IF ANY SANCTION IS ISSUED OTHER THAN A PRIVATE REPRIMAND.
     
     PART C: INFORMATION ABOUT YOUR GRIEVANCE
     
     Explain in detail why you think this attorney has done something improper or has failed to do something which should have been done. Include the names, addresses, and telephone numbers of all persons who know something about your grievance. Attach copies of all court papers, canceled checks or receipts showing the payment of attorney's fees, and other documents relevant to your grievance. Attach additional sheets of paper if necessary.
     (DO NOT SEND ORIGINALS, UNLESS REQUESTED.)
     
     ALSO, PLEASE BE ADVISED THAT A COPY OF YOUR GRIEVANCE MAY BE FORWARDED TO THE ATTORNEY NAMED IN YOUR GRIEVANCE.
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     PART D: ATTORNEY-CLIENT PRIVILEGE WAIVER
     
     I hereby expressly waive any attorney-client privilege as to the attorney, the subject of this grievance, and authorize such attorney to reveal any information in the professional relationship to the Virgin Islands Bar Association.
     
     I also understand this confidential process extends civil immunity to all communications between myself and the Virgin Islands Bar Association Professional Ethics & Grievance Committee. I understand this immunity does not extend to communications I may have with anyone else.
     
     DATE OF SIGNING:
     
     SIGNATURE
     
     RETURN FORM TO:
     
     Virgin Islands Bar Association
     Post Office Box 4108
     Christiansted
     St. Croix, VI 00822-4108