UNITED STATES COURT OF APPEALS FOR THE SEVENTH CIRCUIT VOLUNTEER PANEL ATTORNEY QUESTIONNAIRE Name: _________________________________ E-Mail: _______________________________________ Address: ________________________________________________________________________________ _______________________________________________________________________________________ Telephone: __________________________ Social Security Number (required): ____________________ )HGHUDO (PSOR\HU ,GHQWL¿FDWLRQ 1XPEHU (necessary for tax purposes on vouchers in Criminal Justice Act cases only) ___________________________________________ SUHH[LVWLQJ DJUHHPHQW Z ODZ ¿UP RU FRUSRUDWLRQ Bar Admissions: _________________________________________________________________________ Law school attended and Date of Degree _____________________________________________________ Type of practice: _________________________________________________________________________ , DP FRQYHUVDWLRQDOÀXHQW LQ WKH IROORZLQJ ODQJXDJHV c f Spanish c f Polish c f Chinese c f Other 2WKHU ODQJXDJHV LI PRUH WKDQ RQH SOHDVH VSHFLI\ FRQYHUVDWLRQDOÀXHQWBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB $UH \RX FXUUHQWO\ D PHPEHU RI D SDQHO PDLQWDLQHG E\ D GLVWULFW FRXUW RU )HGHUDO 3XEOLF 'HIHQGHU RI¿FH IRU appointment in district court proceedings? ____ Yes ____ No If "yes", please specify: _____________________________________________________________________ _____ I am interested in accepting Criminal Justice Act appointments from the Court of Appeals, under the guidelines set forth in the Act and the Seventh Circuit Plan for implementation of the Act. I will accept appointment in the following Criminal Justice Act appeals: in ____ direct criminal appeals ____ § 2254 and ____ § 2255 and/or. ____ I am interested in accepting appointment in non-Criminal Justice Act appeals, understanding that there is no statutory authority for the court to compensate me for my time and expenses. I will accept appointment in the following types of non-Criminal Justice Act appeals: ____ Non-prisoner civil rights ____ EEOC ____ Prisoner civil rights ____ Immigration ____ Employee discrimination issues ____ Other matters: please specify: ___________________________ s/ Signature ___________________________________ Date ___________________ Please return this questionnaire and current resume to: Donald J. Wall, Counsel to the Circuit Executive U. S. Court of Appeals 219 South Dearborn Street, #2722 Chicago, IL 60604 don_wall@ca7.uscourts.gov Please complete IRS Form W-9 and return it with this completed questionnaire. rev. ( 04/2012) American LegalNet, Inc. www.FormsWorkFlow.com