Request for Inclusion on the Juvenile Delinquency and Undisciplined Court Appointed List(s) Name: _______________________________ Firm Name: ______________________________________ Address: ____________________________ Phone: ________________ Fax: _________________ ____________________________________ Cell Phone: ___________________ ____________________________________ Wake Courthouse Mailbox #: ___________ NC State Bar #: _______________________ Email: ___________________________________________ Please check all that apply: _____ Yes, my cell phone number may be given to other attorneys on the Juvenile Delinquency and Undisciplined Court Appointed List(s). _____ Yes, my e-mail address may be given to other attorneys that are on the Juvenile Delinquency and Undisciplined Court List(s). I request inclusion on the following lists: Regular Juvenile Cases Major Juvenile Cases THIS SECTION MUST BE COMPLETED FOR INCLUSION ON ANY LIST I certify the following: (Check all that apply) I am licensed to practice law in North Carolina. Year Licensed: ___________ I maintain an office in the 10th Judicial District. I have a local working telephone number, cell phone or pager at which I can be readily contacted. I possess a working facsimile machine and I maintain a mailbox in the Wake County Courthouse. I possess a working email address. I have read N.C.G.S. §§7B-1500 through 3300 in its entirety and am competent with the NC Juvenile Code regarding Juvenile Delinquency and Undisciplined proceedings. I have read the “Tenth Judicial District Family Court Local Rules for Juvenile Delinquency and Undisciplined Proceedings.” I have read, understand, and agree to follow certain policies, procedures, attorney responsibilities, and rules that are, or may be, established for Juvenile Delinquency and Undisciplined proceedings, including, but not limited to, these Rules and the “Regulations for Appointment of Counsel in the 10th Judicial District in Cases under the Indigent Defense Services Act.” THE FOLLOWING ACTIVITIES MUST BE PERFORMED IN THE FOLLOWING ORDER: A. I have completed an Introduction to Juvenile Delinquency Court session conducted by the Chief Court Counselor or that person’s designee. Date: _____________;______________________________ ______________________________________________ Chief Court Counselor’s Signature WAKE-JUV(D&U)-01 (NEW 11/06) (PAGE 1 of 3) American LegalNet, Inc. www.FormsWorkflow.com B. I have observed four full sessions (two full days) of Juvenile Delinquency and Undisciplined Court, including observation on the following dates: _________________ , _________________ , _____________ , _________________; ____________________ ___________ ________________________________________ Court Manager’s Signature C. I have appeared as an unreimbursed co-counsel in three (3) Delinquency cases as certified below and at least one of the three fits the criteria for possible transfer to Superior Court. Three Certifications by Supervising Attorney(s): (1) I, _____________________, a member of the Wake County Juvenile Court Defense Bar, served as supervising attorney for ___________________________, an attorney qualifying to work in the Wake County Juvenile Court handling delinquency cases on an appointed basis, in the following case: File #: _________________________ Charges:________________________________ Adjudication Date: _______________ Judge:__________________________________ Disposition: ____________________ ________________________________________ Signature of Supervising Attorney (2) _______________ Date I, _____________________, a member of the Wake County Juvenile Court Defense Bar, served as supervising attorney for ___________________________, an attorney qualifying to work in the Wake County Juvenile Court handling delinquency cases on an appointed basis, in the following case: File #: _________________________ Charges:________________________________ Adjudication Date: _______________ Judge:__________________________________ Disposition: ____________________ _________________________________________ Signature of Supervising Attorney (3) _______________ Date I, _____________________, a member of the Wake County Juvenile Court Defense Bar, served as supervising attorney for ___________________________, an attorney qualifying to work in the Wake County Juvenile Court handling delinquency cases on an appointed basis, in the following case: File #: _______________________ Charges:________________________________ Adjudication Date: _____________ Judge:__________________________________ Disposition: __________________ ________________________________________ Signature of Supervising Attorney _______________ Date WAKE-JUV(D&U)-01 (NEW 11/06) (PAGE 2 of 3) American LegalNet, Inc. www.FormsWorkflow.com THIS SECTION MUST ONLY BE COMPLETED FOR INCLUSION ON THE MAJOR JUVENILE LIST. I have complied with the procedures and requirements to be included on List 3 (Adult List – A through E Felonies) as set forth in Article IX, A and B of the “Regulations for Appointment of Counsel in the 10th Judicial District in Cases under the Indigent Defense Services Act”. OR I am currently on the Adult List 3 – A through E felonies. Signature of the Requesting Attorney: _____________________________________________ Attorney Date: ______________________________________ This attorney meets all of the requirements for inclusion on the following lists: Regular Juvenile Cases Major Juvenile Cases ______________________________________________ Family Court Administrator (or designee) Date: ________________________________________ For use by Committee on Indigent Appointments Only - Request for Inclusion on: Regular Juvenile Cases Approved Denied Major Juvenile Cases Approved Denied _____________________________________________ Public Defender Date: ________________________________________ WAKE-JUV(D&U)-01 (NEW 11/06) (PAGE 3 of 3) American LegalNet, Inc. www.FormsWorkflow.com