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If you are new to the site and would like to access our protected resources, please register using the form below. All fields are required except where indicated. Please review our terms and conditions and privacy policy.

Please complete the form below to register:
Personal Information
First Name:		Last Name:
E-mail Address:		Confirm E-mail:
Password:		Confirm Password:
Mailing Address:	Street:	City:	State and Zipcode:
Contact Numbers:	Phone:	Fax (optional):	Mobile (optional):
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About Your Practice
Nature of Practice:	Full-time Black Lung Part-time Black Lung Lay Advocate Other If other, please specify:
Years of Practice:	In Virginia: Overall: Please list number of claimants represented at trial level and appeal, and indicate as lead counsel, second chair, or other.
Have you worked with the W&L Black Lung Clinic previously?	Yes No If yes, inidcate name of client(s):
Certification
By selecting the checkbox below, I certify that: I am actively engaged, or plan to be engaged, in Black Lung claimant representation. I am not employed by any coal companies or firms that are adverse parties in Black Lung claims and have no present plans to become so employed. I understand and agree that the password is nontransferable. access to this site is limited to persons engaged, or preparing to be engaged, in claimant representation in Black Lung cases. I will respect and not compromise the confidentiality of the site. I agree to the above: