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Application for Assistance

- Personal Information
- Where are you located?*
- Mention the name of other location:*
- First Name:*
- Last Name:*
- Date of Birth (dd/mm/yyyy):*
- Address:*
- Email Address:*
- Cell Phone:*
- Home Phone:
- Work Phone:
- Please select the phone number(s) we can leave voicemails on:
  - Cell Phone
  - Home Phone
  - Work Phone
- What type of program/ service do you require?*
- Not sure? (click here) More information on Civil Claims Duty Counsel
  More information on Queen's Bench Amicus Court
- How do you wish to receive assistance?*
  - Telephone
  - Videoconference
Case Information
- I am the:*
  - Plaintiff
  - Defendant
  - Unsure/Not Applicable
  Plaintiff: the person suing for a claim
  Defendant: the person being sued for a claim
- Please list all of the Plaintiff’(s) names relating to this matter: (full names of all individuals, company names and trade names)*
- Please list all of the Defendant’(s) names relating to this matter: (full names of all individuals, company names and trade names)*
- Please list any other persons or companies that might be involved in your matter:*
- Do you have an upcoming court date?*
  - Yes
  - No
  If you're unsure of have more details, add them by selecting "Other."
- Court Date:*
- Court Date Time*
  
  : HH
  
  MM
- What is the nature of that appearance?*
  - Motion
  - Trial
  - Mediation
  - Pre-Trial Conference
- Do you need to create court documents today?*
  - Yes
  - No
  - Maybe
- Do you need services in another language?*
  - Yes
  - No
  Please note: PBLA does not provide interpretation/translation services, but you may arrange for an interpreter/translator to attend the appointment with you.
- If yes, please provide the email address of the interpreter/translator who will attend the appointment with you.
Additional Information
- Briefly tell us what your case is about. Please include names, dates and a brief description of your issue. Why are you seeking legal help today?*
- What specific questions would you like to ask the lawyer?
- 1)*
- 2)
- 3)
- Do you have any other cases pending in the Alberta justice system at this moment?*
  - Yes
  - No
  - Unsure
- 2. Does the opposing party have a lawyer or representative?*
  - Yes
  - No
  - Unsure
- 3. Do you currently have a lawyer or other representative currently helping you with this case?*
  - Yes
  - No
- 4. Has a lawyer ever assisted you with this case?*
  - Yes
  - No
- If yes, why is that lawyer no longer assisting you?*
- Is this your first meeting with a Duty Counsel lawyer through this program?*
  - Yes
  - No
- I HEREBY REPRESENT THAT THE information that I have provided is true and accurate to the best of my knowledge and belief.
- Print name:*
  This must be your legal name as it appears on legal documents and identification.
- Date (dd/mm/yyyy):*
  Please enter today's date.

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