Burns Less Application First Name Last Name Title preference Mr. Mrs. Ms. Dr. Miss Hon. Rev. Rabbi Rep. Sen. Master Sir Lady Mr.? Ms.? etc. Business Name (if you have one) Street Address e.g., 123 Main Street Suite, Apartment, Studio No. City State/Province Zip/Postal Code Country USA Canada Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua & Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bailiwick of Guernsey Bailiwick of Jersey Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iraq Ireland Islamic Republic of Iran Isle of Man Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Democratic Peoples Republic of Korea, Republic of Kosovo Kuwait Kyrgyzstan Lao People’s Democratic Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nambia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthélemy Saint Lucia Saint Martin Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka St. Helena St. Kitts and Nevis St. Pierre & Miquelon St. Vincent & the Grenadines Sudan Suriname Swaziland Sweden Switzerland Syrian Arab Republic Taiwan, ROC Tajikistan Tanzania, United Republic of Thailand Togo Tokelau Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Virgin Islands Unknown/Other Uruguay USA Uzbekistan Vanuatu Vatican City State (Holy See) Venezuela Viet Nam Wallis & Futuna Islands Yemen Yugoslavia Zaire Zambia Zimbabwe Email Website Phone include country code if not USA What kind of creative are you e.g., photographer, painter, or a hyphenate of creativity like writer-director What sort of legal needs do you think you’ll have, generally, like "registration questions" or "contracts reviewed" This is just to give me an idea of your wants/needs Clicking this box means you understand that submitting this form does not create a client-attorney relationship between you and Leslie. There is no representation until you and Leslie sign an agreement.