Board of Law Examiners Appointed by the Supreme Court of Texas DECLARATION OF INTENTION TO STUDY LAW This form is to be filed by all persons who have begun their law study to obtain a Juris Doctorate degree at ABAapproved law schools in Texas and intend to apply for licensure in Texas. Do not file this form until you have actually started law school. You are responsible for reading the current Rules Governing Admission to the Bar of Texas and the applicable statutory provisions found in Texas Government Code, Sec. 82.001 et seq., all of which are contained in the booklet titled: Rules Governing Admission to the Bar of Texas. The rulebook is available in downloadable format on the Board’s website, www.ble.state.tx.us. Carefully follow these instructions and complete this form, typing or printing your answers. Use blue or black ink if you choose to print your answers. Keep a copy of your Declaration for future reference, as you may be charged for any copies you request from the Board’s file. Before you file your Declaration, verify that you have fully answered all questions, leaving no blanks, and that you have completed all required Continuation Forms, Civil Litigation Forms, and Criminal History Forms. (If a question is inapplicable, write “N/A.”) Incomplete Declarations may be returned and, if applicable, a late fee of $150.00 will be imposed. Your Declaration will not be considered filed and may be returned to you if it is incomplete. Examples of incompleteness include, but are not limited to the following: a. failure to provide supervisor information, where required; b. failure to provide telephone numbers, where required; c. failure to provide complete mailing addresses, including zip codes, where required; d. failure to answer any question or subquestion; e. failure to provide your LSAC account number; f. failure to provide completed Continuation Forms, Civil Litigation Forms and Criminal History Forms for each question requiring them; g. failure to send the required fees; h. any signature notarized more than 90 days before the date received in the Board’s offices; i. alteration of any of the language of the Declaration, Affidavit or Authorization and Release; or j. failure to sign any document requiring your signature and/or failure to have your signature notarized where required. If you have not enclosed required documentation that you must obtain from third parties (i.e., certified copy of birth certificate, court records, etc.), detail on a Continuation Form as required in Question 20. You must make a good faith effort to provide these items within 30 days of our receipt of your Declaration. Your failure to meet this deadline may cause your Declaration to be returned to you as not being properly filed. This 30-day grace period DOES NOT APPLY to the Continuation Forms, Civil Litigation Forms, and Criminal History Forms, which must be filed with your Declaration, if applicable. 1. Filing Fees: Your check, money order, or bank cashier’s check should be made payable to the Board of Law Examiners (NOT the State Bar of Texas). Check the charts below to determine the amount of fees you owe. TIMELY FILING DEADLINES FEES OWED Fall Entrants October 1 If filed on or before timely filing deadline $190.00 Semester Hr/Spring Entrants May 1 If filed after timely filing deadline $340.00 Quarter Hr/Spring Entrants June 1 Summer Entrants September 15 Do not postdate your check. A Declaration is not considered filed until all associated fees are received in the Board office. If your check for fees is returned for insufficient funds or is otherwise dishonored by your bank, you will be assessed a returned check charge. In addition, you will be assessed a late fee if the timely deadline has passed, which will result in fees totaling $340.00. All fees due after that time must be paid by bank cashier’s check or money order. A $150.00 late fee will be incurred for Declarations filed after the timely deadline, which will result in a total of $340.00 in fees. A late Declaration will be accepted with the payment of the late filing fee provided that the Declaration and required fees are filed in accordance with the application filing deadlines set forth in Rule IX. However, regardless of the date a Declaration is filed, the Board shall have 270 days from the date the Declaration is filed to conduct its character and fitness investigation and notify the Declarant of the Board’s determination, as provided in Rule VIII(a). There is NO refund of fees in the event of withdrawal or rejection of a Declaration. i BLE-1.pdf (10/2010) 2. Filing of Declaration: Mail or deliver your Declaration and all required fees to the Board as shown below: MAILING ADDRESS: Board of Law Examiners P.O. Box 13486 Austin, TX 78711-3486 3. 4. 5. 6. 7. 8. 9. 10. DELIVERY ADDRESS: Board of Law Examiners 205 West 14th Street, 5th Floor Austin, Texas 78701 All filing deadlines are postmark deadlines (i.e., if your envelope bears a postmark date on or before the deadline, it will be considered timely filed). If the Postal Service fails to postmark your envelope or the postmark is illegible, your Declaration will be deemed to have been filed on the day preceding its receipt by our office. Therefore, you are strongly advised to mail your Declaration by certified mail, return receipt requested, and have your receipt postmarked at the post office, so that you will have documentation of the date you mailed it. If you file your Declaration in person, it must be received in the Board’s office on or before the applicable deadline. The Board office is not open on weekends or state holidays. Declaration filing deadlines are strictly construed. The Board will acknowledge receipt of your Declaration by letter. If you do not receive an acknowledgment within 30 days, please contact the Board’s office. Authorization/Release Forms: Provide two (2) ORIGINAL, SIGNED, and NOTARIZED Authorization/Release forms. Do not send copies. Blank forms are attached for your use. These forms must be filed simultaneously with your Declaration. Proof of Citizenship Status: You must provide the applicable documents requested in Question 7. These documents become part of the Board’s permanent file and will not be returned to you. Photocopies of birth certificates will not be accepted. Proof of Name Change: You must provide a certified copy of an amended birth certificate or portion of divorce decree or court order which changes your name. If your name changed by marriage, submit a legible copy of your marriage license. These documents become a part of the Board’s permanent file and will not be returned to you. Continuation Forms: One Continuation Form is included with the Declaration; make additional copies as needed. Analyze the Declaration carefully to determine how many forms you will need before you mark on the one copy provided. Use this form as directed in various questions in the Declaration to provide an explanation for “yes” answers and to continue your answers if additional space is required to complete responses to any question or statement for which a specifically designated form is not provided. Respond to only one question or statement on each Continuation Form. If applicable, these forms must be filed simultaneously with your Declaration. Do not forget the requirement in Question 20 to list on a Continuation Form all documentation not provided with your Declaration. Civil Litigation Forms: A Civil Litigation form is included with the Declaration; make additional copies as needed. Use this form as directed in the Declaration. If applicable, these forms must be filed simultaneously with your Declaration. Criminal History Forms: A Criminal History form is included with the Declaration; make additional copies as needed. Use this form as directed in the Declaration. If applicable, these forms must be filed simultaneously with your Declaration. Expunged and Sealed Offenses: Matters expunged pursuant to Texas Code of Criminal Procedure Art. 55.02, or pursuant to another State’s statute with the same force and effect, need not be disclosed. While expunged or sealed offenses, arrests, tickets, or citations need not be disclosed, it is your responsibility to ensure the offense, arrest, ticket, or citation has, in fact, been expunged or sealed. It is recommended that you obtain a copy of the Court Order expunging or sealing the record in question. Failure to reveal an offense, arrest, ticket, or citation that is not in fact expunged or sealed, raises questions related to truthfulness in addition to questions regarding the offense itself. Orders of Non-Disclosure: Pursuant to the Govt. Code §552.142 (b), if you have criminal matters that are the subject of an order of non-disclosure you are not required to reveal those criminal matters on this form. However, a criminal matter that is the subject of an order of non-disclosure may become a character and fitness issue. Pursuant to other sections of the Government Code 411.081(d), 411.081(i)(5), 411.083(b), 411.084(a), 411.087(a), and 411.100, the Texas Board of Law Examiners is entitled to access criminal history record information that is the subject of an order of nondisclosure. Therefore, if the BLE discovers a criminal matter that is the subject of an order of non-disclosure, even if you properly did not reveal that matter, the BLE may ask you to provide information about that criminal matter. ii BLE-1.pdf (10/2010) 11. Employment History: (a) If an employer is no longer in business, you should enter the phrase “no longer in business” on the line for the supervisor’s name, instead of listing the name of your supervisor. Enter the last known address for the business. (b) If your immediate supervisor is no longer employed by an employer, you have a choice: either list the name of another supervisor still employed by the employer who will be able to respond to an inquiry from the Board staff as to your honesty, etc., or list the current address of your former supervisor, wherever that person is now, or, if neither is a viable option, state “personnel department.” 12. 13. 14. 15. 16. 17. 18. 19. (c) If you cannot locate any documentation that indicates the exact dates you were employed, list the approximate dates, but indicate that they are approximate. (d) If you were employed in a non-paid, intern-type position, you should list such employment situations. Board staff will elicit responses as to your honesty, etc., so the fact that you were not paid is not important. FBI Fingerprint Check: A fingerprint check with the Federal Bureau of Investigation is mandatory. The staff of the Board of Law Examiners cannot complete the investigation of your Declaration without the results of your FBI fingerprint check. Current information on the fingerprinting requirement is available on the Board’s website, www.ble.state.tx.us, under the links Fingerprinting, Fingerprinting for Declaration of Intent to Study Law. Court Records: Provide legible copies of all requested court records as specified on the Declaration. Law School Application: Provide a legible signed copy of the application you filed with each law school you have attended. Change of Address: The Declaration contains a change of address notification form. Keep this page and use it to submit any address change to the Board office, as the Board will rely on your last known address in its communications with you. Do not rely on the BLE staff to change your mailing address of record based solely on your return address listed on other correspondence sent to this office. TDD Contact: To contact the Board from a Telecommunication Device for the Deaf call Relay Texas at 1800-RELAYTX. Full Disclosure: It is imperative that you honestly and fully answer all questions, regardless of whether you believe the information requested is relevant. Your responses on your Declaration are evaluated as evidence of your candor and honesty. An honest “yes” answer to a question on your Declaration is not definitive as to the Board’s assessment of your present moral character and fitness, but a dishonest “no” answer is evidence of a lack of candor and honesty, which may be definitive on the character and fitness issue. Obligation to Update: You are obligated to update the Board of any matters required by the language contained in the Affidavit section of the Declaration. LSAC Account Number: You must provide your Law School Admission Council’s (LSAC) Account Number if you are applying to take the Texas Bar Examination. The link for the LSAC account number lookup is http://lsaclookup.lsac.org/lookup.aspx. If you have interacted with LSAC in any way, you have an LSAC account number. If you do not have an LSAC account number, you need to create an account by going to http://lsaclookup.lsac.org/lookup.aspx. Your Declaration will be returned if you leave the LSAC account number field blank. CAUTION!! The Declaration is the first step in a two-step process for admission to the Bar of Texas. You cannot take the Texas Bar Examination based solely upon the filing of this Declaration. A separate Application and a separate filing fee will be required when you apply to take the Texas Bar Examination. Refer to the Rules Governing Admission to the Bar of Texas for application filing deadlines. iii BLE-1.pdf (10/2010) Board of Law Examiners Mailing Address: P. O. Box 13486, Austin TX 78711-3486 Physical Address: 205 West 14th Street, 5th Floor, Austin TX 78701 DECLARATION OF INTENTION TO STUDY LAW (This form is to be filed ONLY by persons who will receive or have received a J.D. degree from an ABA-approved law school in Texas.) ____ Mr. NAME: ____ Ms. ______________________ Date of Birth MAILING ADDRESS: Last First _____________________ Social Security No.* Middle ______________________ Driver’s License/I.D. No. Maiden _________________ Issuing State (All correspondence will be mailed to this address.) ______________________________________ Street Address/P.O. Box Apt. No. __________________________ City ___________ State ____________ Zip Code Home Phone: ___________________ Work Phone: _____________________ Cell Phone: ____________________ E-mail Address: ___________________________________________________ NAME & TELEPHONE NUMBER OF PERSON WHO CAN CONTACT YOU: __________________________________ ______________________________ Name Relationship __________________________ Telephone Number What date do you expect to take the Texas Bar Examination? Month (February or July) and Year RESIDENCES: List each city, including any in Texas, and state, and/or foreign country in which you have resided, worked, or attended school for three (3) consecutive months or longer during the last ten (10) years. Use a Continuation Form if necessary. You must include entries covering the past ten (10) years. Do not answer “N/A” for this item. From (mm/yy) To (mm/yy) City, State (and Foreign Country, if applicable) 1. Have you ever been known by any other name or surname? If you answered “YES,” give the following information: Other Complete Name Duration of Use _________Yes _______No Explanation of Change 2. (a) List the name of the law school you are currently attending, or have previously attended, and provide a legible, signed copy of your application to each law school. If you need additional space, continue your response on a Continuation Form. PRESENT LAW SCHOOL: _____________________________ Date Began: ________________________________ PREVIOUS LAW SCHOOL: ____________________________ Location: _________________________________ From: ____________________ To: _______________________ *The provision of your social security number is voluntary, pursuant to Sec. 7, Privacy Act of 1974. However, when this data is provided, the Board will use it in its investigation and verification to minimize errors of identity that might introduce problems and delays into the certification and licensure process. The Board appreciates your furnishing this information on a voluntary basis. 1 BLE-1.pdf (10/2010) LAW SCHOOL ADMISSION COUNCIL (LSAC) Account Number: __________________________ (Refer to item 19 of the General Instructions.) (b) Have you, within the last ten (10) years, been the subject of a determination of misconduct or irregularity by the Law School Admission Council (LSAC)? _________ (yes or no) If you answered “YES” to Question 2(b), provide a narrative explanation on a Continuation Form, and provide legible copies of all relevant documents. __________ Check here if a Continuation Form is attached. 3. (a) List all colleges or universities attended (starting with institution most recently attended). If you need additional space, use a Continuation Form. (1) Institution Dates of Attendance Street/P.O. Box City Institution Dates of Attendance Street/P.O. Box City Degree State/Country Zip/Postal Code (2) Degree State/Country Zip/Postal Code _________ Check here if a Continuation Form is attached. (b) Have you ever been disciplined in any way for any matter by any college, university, law school or other institution of higher learning, or by any professor, administrator, employee or entity representing any college, university, law school or other institution of higher learning, or have you been allowed to withdraw from such an institution to avoid such discipline, whether or not the record of such action was retained in your file? (Discipline includes, without limitation, a letter or other written notice of reprimand or warning, suspension, expulsion, adjustment of grade, assignment of community service, any form of probation, or any other adverse action). (Entity includes, without limitation, residential facilities or other facilities owned or managed by a college, university, law school, or other institution of higher learning.)……………………………………………………………………………………. _________ (yes or no) If you answered “YES” to Question 3(b), provide a narrative explanation on a Continuation Form, and provide legible copies of all relevant documents. __________ Check here if a Continuation Form is attached. 4 During the last ten (10) years, have you been terminated, suspended, disciplined, or permitted to resign in lieu of termination, suspension, or discipline, from any job or employment?…………….. _________ (yes or no) If you answered “YES” to Question 4, attach a Continuation Form on which you provide a narrative explanation of the circumstances surrounding each such occurrence. __________ Check here if a Continuation Form is attached. 2 BLE-1.pdf (10/2010) 5. REFERENCES: (a) Beginning with your current or most recent employment, list all employment (including self-employment, externships, paid and unpaid internships, clerkships, part-time employment, and temporary employment) you have held for any period of time since your 18th birthday or during the last ten (10) years, whichever period is shorter. Refer to item 11 of the General Instructions for additional guidance in providing employment data. Use the Employment Form on page 15 if you list more than two (2) employers. (1) NAME OF EMPLOYER: _____________________________________________________________ CURRENT ADDRESS: _______________________________________________________________ Street City TELEPHONE NUMBER: _____________________ State Zip DATES EMPLOYED: _______________________ From (mm/dd/yy) Area Code To (mm/dd/yy) POSITION HELD: __________________________ NAME OF SUPERVISOR:____________________ REASON FOR LEAVING: ____________________________________________________________________ (2) NAME OF EMPLOYER: ___________________________________________________________________ CURRENT ADDRESS: _____________________________________________________________________ Street City TELEPHONE NUMBER: ________________________ Area Code State DATES EMPLOYED: ________________________ From (mm/dd/yy) POSITION HELD: _____________________________ Zip To (mm/dd/yy) NAME OF SUPERVISOR: _____________________ REASON FOR LEAVING: __________________________________________________________________ _________ Check here if an Employment Form(s) and/or a Continuation Form(s) is attached relating to Question 5(a). (b) List six (6) character references who can give information about your past activities and candid opinions concerning your character. Do not list relatives, law students, or any person named in your responses to item number 5(a) (employment history). (1) Name City Street Address State Zip Daytime phone number (2) Name City Street Address State Zip 3 BLE-1.pdf (10/2010) Daytime phone number (3) Name City Street Address State Zip Daytime phone number (4) Name City Street Address State Zip Daytime phone number (5) Name City Street Address State Zip Daytime phone number (6) Name City 6. Street Address State Zip Daytime phone number Have you, within the last ten (10) years, served in the Armed Forces of the United States of America? ________ (yes or no) If you answered “YES” to Question 6, attach a Continuation Form with a summary of your current or past service in the Active, Reserve, or National Guard forces. You must include a detailed explanation of any administrative or disciplinary proceedings brought against you in the armed forces. In addition, if you have completed any active duty service in the Armed Forces, provide a legible copy of your DD Form 214 (Certificate of Release or Discharge From Active Duty), which indicates your character of service. (If you do not have a copy, you may obtain one by writing to National Personnel Records Center, Military Personnel Records, 9700 Page Blvd., St. Louis, MO 63132.) For completed service with the Reserve or National Guard forces, provide a legible copy of your discharge document. __________ Check here if a Continuation Form is attached. 7. Are you presently: a United States citizen or National?………………………………………………………………………… ________ (yes or no) an alien lawfully admitted to the U.S. for permanent residence?……………………………………...…… ________ (yes or no) an alien authorized to work lawfully in the United States?……………………………………………………… ________ (yes or no) You will not be eligible to be licensed in Texas until you have achieved a status set forth in Rule II (a)(5), Rules Governing Admission to the Bar of Texas, although you may take the applicable examination prior to achieving such status. If born a U. S. citizen or National: Provide an official birth certificate issued by city/county/state/federal certifying authority (if born in the United States) OR an official Consular Report of Birth (if born abroad to U.S. citizen/parent). Photocopies will not be accepted. Do not submit a foreign birth certificate. 4 BLE-1.pdf (10/2010) If a naturalized U. S. citizen: Provide a legible copy of both sides of your Certificate of Naturalization or Certificate of Citizenship. Do not submit a foreign birth certificate. If any other status: Provide a legible copy of both sides of the USCIS document evidencing your current status. Do not submit a foreign birth certificate. 8. A person who is recommended for licensure to practice law in the State of Texas must execute an oath of office upon licensure and must swear, among other things, that he/she “...will support the Constitution of the United States, and of this State...” Will you execute the required oath of office if you are recommended for licensure in the State of Texas? ………………………………………………………………………………..……………… ________ (yes or no) If you answered “NO” to Question 8, explain your answer on a Continuation Form. __________ Check here if a Continuation Form is attached. 9. (a) Are you presently, or have you been within the last ten (10) years, a party to any civil suit or proceeding (including any matters in which you were the subject of a proceeding for commitment based on incompetency, mental health, or substance abuse)?……………………………………………………………………….…... ________ (yes or no) If you answered “YES” to Question 9(a), attach a separate Civil Litigation Form for each matter. On each Form, indicate in the “Disposition” section whether the matter has been concluded or is still pending. If you are, or were, a plaintiff, you must complete the Form, but you are not required to attach any documentation. If you were a defendant in a matter that has been concluded, attach a legible copy of the docket sheet. If a judgment was rendered against you, attach a legible copy of the judgment and proof of satisfaction, if applicable. Provide an explanation if the judgment has not been satisfied. If the matter resulted in a settlement, provide a summary of the terms as they relate to you and a statement as to whether you adhered to same. If you are a defendant in a matter that is pending, attach a legible copy of the docket sheet and a legible copy of the most recent petition/complaint. __________ Check here if a Civil Litigation Form is attached. (b) Have you ever been convicted of an offense, placed on probation, or granted deferred adjudication or any type of pretrial diversion? You must report any such offenses involving alcohol or drugs. You must report any failure to appear conviction resulting from any offense. You must report any conviction for failure to maintain financial responsibility (legally required auto insurance). You may exclude only Class C misdemeanor traffic violations………………………………………………………………………………………………..…...… ________ (yes or no) (c) Have you, within the last ten (10) years, been arrested, cited or ticketed for, or charged with any violation of the law? You must report any offenses involving alcohol or drugs. You must report any failure to appear charge or warrant resulting from any such offense. You must report any such failure to maintain financial responsibility (legally required auto insurance), arrest, citation, ticket, or charge. You may exclude only Class C misdemeanor traffic violations………………………………………………………………….. ________ (yes or no) If you answered “YES” to Question 9(b) or (c), attach a completed Criminal History Form for each arrest, charge, citation, or ticket. 5 BLE-1.pdf (10/2010) Arrest/offense reports: If any of the offenses you describe resulted from an arrest (as opposed to a citation or a ticket) that occurred within five years of the date you sign this Declaration, you are responsible for either providing legible copies of the arrest/offense reports for such offenses, or providing proof that you made a written request for such reports. You are not required to provide copies of citations or tickets. Court records: If any of the offenses you describe (whether they resulted from an arrest, citation, or ticket) occurred within five years of the date you sign this Declaration, you are responsible for either providing legible copies of all court records for all such offenses, or providing proof that you made a written request for such court records. It is very important that you make your written requests to the correct agency or court. __________ Check here if a Criminal History Form is attached. NOTE: If you have ever been convicted of a felony, or have been placed on probation for a felony, with or without an adjudication of guilt, read Rule IV(d) carefully. You may be prohibited from filing this form. NOTE: Expunged and Sealed Offenses: Matters expunged pursuant to Texas Code of Criminal Procedure Art. 55.02, or pursuant to another State’s statute with the same force and effect, need not be disclosed. While expunged or sealed offenses, arrests, tickets, or citations need not be disclosed, it is your responsibility to ensure the offense, arrest, ticket, or citation has, in fact, been expunged or sealed. It is recommended that you obtain a copy of the Court Order expunging or sealing the record in question. Failure to reveal an offense, arrest, ticket, or citation that is not in fact expunged or sealed, raises questions related to truthfulness in addition to questions regarding the offense itself. NOTE: Orders of Non-Disclosure: Pursuant to the Govt. Code §552.142 (b), if you have criminal matters that are the subject of an order of non-disclosure you are not required to reveal those criminal matters on this form. However, a criminal matter that is the subject of an order of non-disclosure may become a character and fitness issue. Pursuant to other sections of the Government Code 411.081(d), 411.081(i)(5), 411.083(b), 411.084(a), 411.087(a), and 411.100, the Texas Board of Law Examiners is entitled to access criminal history record information that is the subject of an order of non-disclosure. If the Board of Law Examiners discovers a criminal matter that is the subject of an order of non-disclosure, even if you properly did not reveal that matter, the Board of Law Examiners may ask you to provide information about that criminal matter. (d) Are you currently the target or subject of a grand jury or other governmental agency investigation?... ________ (yes or no) If you answered “YES” to Question 9(d), attach a Continuation Form on which you provide details. __________ Check here if a Continuation Form is attached. (e) Have you, within the last ten (10) years, filed or been the subject of a petition in bankruptcy?……… ________ (yes or no) (1) Were there any allegations of fraud or mismanagement of funds?………………………….. ________ (2) Were any adversary proceedings instituted?…………………………………………………. ________ (yes or no) (yes or no) 6 BLE-1.pdf (10/2010) If you answered “YES” to any part of Question 9(e), attach a Continuation Form on which you provide details as to your responses, including the final or current disposition of the matter. In addition, provide legible copies of the bankruptcy petition, all schedules, discharge order (if applicable), and other pleadings relevant to your responses. If you filed a Chapter 7 Petition that resulted in a discharge, include a statement as to whether any of your scheduled debts were not discharged. __________ Check here if a Continuation Form is attached. (f) Have you, within the last ten (10) years, been charged with fraud, or alleged to have committed fraud, in any criminal or civil proceeding?…………………………………………………………………….…………. ________ (yes or no) If you answered “YES” to Question 9(f), attach a Continuation Form on which you provide details as to your response. In addition, provide legible copies of relevant court documents, including pleadings and orders relating to the fraud allegations. __________ Check here if a Continuation Form is attached. 10. Have you, within the last ten (10) years, abused or been addicted to, or treated for the use or abuse of alcohol or any other substance, to include any court-ordered treatment?……………………………………………… ________ (yes or no) If you answered “YES” to Question 10, provide details on a Continuation Form. Include the dates of treatment and the name, current mailing address, and telephone number of each person who provided evaluation or treatment, as well as the dates of treatment and the name, current mailing address, and telephone number of each facility where you received treatment. __________ Check here if a Continuation Form is attached. 11. If you have received mental health counseling or have been hospitalized for mental health reasons and do not know the diagnosis which was made, you should contact the health care provider responsible for your care and inquire as to whether you were diagnosed with bi-polar disorder, schizophrenia, paranoia, or any other psychotic disorder. In answering the following questions, you are entitled to rely on the diagnosis of your treating health care provider. You do not need to report any counseling, treatment, or hospitalization, which was for a diagnosis other than those included in the following questions. A “yes” response to either of the following questions does not mean necessarily that you will be found to lack the fitness required for admission to the Bar. The Board is sensitive to confidentiality concerns. Please refer to Rule I(d) of the Rules Governing Admission to the Bar of Texas concerning confidentiality. (a) Within the last ten (10) years, have you been diagnosed with, or have you been treated for, bi-polar disorder, schizophrenia, paranoia, or any other psychotic disorder?……………………...……………………………. _______ (yes or no) (b) Have you, since attaining the age of eighteen or within the last ten (10) years, whichever period is shorter, been admitted to a hospital or other facility for the treatment of bi-polar disorder, schizophrenia, paranoia, or any other psychotic disorder?……………………………………..……………………………………………. ________ (yes or no) 7 BLE-1.pdf (10/2010) If you answered “YES” to any part of Question 11, provide details on a Continuation Form. Include date(s) of diagnosis and treatment, a description of your course of treatment and a description of your present condition. Include the name, current mailing address, and telephone number of each person who treated you, as well as each facility where you received treatment, and the reason for each treatment. You may also include information as to why, in your opinion or that of your health care provider, your illness or disorder will not affect your ability to practice law in a competent and professional manner. __________ Check here if a Continuation Form is attached. 12. (a) Have you ever been ordered by a court to pay child support?…………………………………………….. ________ (yes or no) If you answered “YES” to Question 12(a), attach a Continuation Form on which you provide the name, current mailing address, and telephone number of the payee and the agency (if any) receiving your payments. In addition, provide legible copies of relevant documents (including court orders and agreements incident to divorce). __________ Check here if a Continuation Form is attached. (b) Are you now, or have you been within the last ten (10) years, past due in any such court-ordered child support payments?…………………………………………………………………………………………… ________ (yes or no) (c) Has an arrearage judgment been taken against you?……………………………………………………… ________ (yes or no) If you answered “YES” to Question 12(b) or (c), explain your response on a Continuation Form. In addition, provide legible copies of relevant documents, including court orders. __________ Check here if a Continuation Form is attached. 13. Have you ever been held in contempt or sanctioned by a court? ........................................................................ ________ (yes or no) If you answered “YES” to Question 13, explain your response on a Continuation Form and provide legible copies of the court order(s). __________ Check here if a Continuation Form is attached. 14. (a) Do you have any student loan debts that are ninety (90) days or more past due?………………………… ________ (yes or no) If you answered “YES” to Question 14(a), attach a Continuation Form on which you provide the name, mailing address, and telephone number for the creditor(s), the amount owed, the account number, the reason for the delinquency, and your intentions as to the debt. __________ Check here if a Continuation Form is attached. (b) Do you have any other debts that are ninety (90) days or more past due (including tax debts owed pursuant to federal or other law)?……………………………………………………………………………… ________ (yes or no) 8 BLE-1.pdf (10/2010) If you answered “YES” to any part of Question 14, provide a current credit report from EXPERIAN (1888-397-3742 or you may obtain a report from the internet at www.experian.com). When you provide a credit report, list any debt(s) you dispute and explain why you dispute them. Also, list any debts that are ninety (90) days or more past due that are not shown on the credit report. 15. (a) Have you, within the last ten (10) years, failed to timely file any applicable state or federal income tax return and/or report required by law?…………………………………………………………………………. ________ (yes or no) (b) Have you, within the last ten (10) years, failed to pay any taxes owed pursuant to state or federal law at the time such taxes were due?…………………………………………………………………………. ________ (yes or no) (c) Have you, within the last ten (10) years, collected federal withholding, social security, or Medicare taxes from the wages of your employees, and failed to timely report and forward such monies to the Internal Revenue Service?……………………………………………………………………………………………………….. ________ (yes or no) If you answered “YES” to any part of Question 15, attach a Continuation Form, providing details. In addition, furnish copies of all correspondence that relate to the matters covered in your explanation. __________ Check here if a Continuation Form is attached. 16. (a) Do you currently have an application for admission to the bar, or an application to take a bar examination, pending in another jurisdiction?……………………………………………………………………………... ________ (yes or no) (b) Have you ever initiated the process to become licensed to practice law, or have you ever filed an application to take a bar examination, in any jurisdiction (including Texas) and were not licensed in that jurisdiction? (This question does not refer to applications to law schools.)…………………………………. ________ (yes or no) (c) Have you ever filed a law student registration document in any jurisdiction and were not ultimately licensed in that jurisdiction? (This question does not refer to applications to law schools.)………………………… ________ (yes or no) If you answered “YES” to any part of Question 16, provide details on a Continuation Form, including the jurisdiction, dates, and other details. __________ Check here if a Continuation Form is attached. (a) During the last ten (10) years, have you applied for any professional or occupational license?………….. ________ (b) Are you now, or have you ever been, licensed in any professional or occupational capacity?…………… 17. ________ (yes or no) (yes or no) If you answered “YES” to Question 17(a) or (b) provide details on a Continuation Form, including license held, or applied for, date issued and the name, address and telephone number of the licensing authority. If the license was not issued, please explain. __________ Check here if a Continuation Form is attached. (c) Have you ever been disbarred, suspended from practice, disciplined, disqualified, placed on a diversion program, or allowed to resign in lieu of disciplinary action, or has your license ever been qualified or conditioned in any way, as a member of any profession, licensed occupation, or as the holder of any public office?…………………………………………………………………………………………………………. ________ (yes or no) 9 BLE-1.pdf (10/2010) (d) Have there ever been any charges, complaints, or grievances (formal or informal) filed (regardless of the outcome) concerning your conduct as a member of any profession, licensed occupation, or as the holder of any public office?…………………………………………………………………………………………………… ________ (yes or no) (e) Are there now pending any charges, complaints, or grievances (formal or informal) concerning your conduct as a member of any profession, licensed occupation, or as the holder of any public office?……….. ________ (yes or no) If you answered, “YES” to Question 17(c), (d), or (e), provide a narrative statement of the details stating dates, names and circumstances) on a Continuation Form. Include the name and mailing address of the disciplinary authority in possession of the records of such incidents. __________ Check here if a Continuation Form is attached. 18. Have you, within the last ten (10) years, been the subject of an investigation for the unauthorized practice of law?……………………………………………………………………………………………………………. ________ (yes or no) If you answered “YES” to Question 18, provide the details on a Continuation Form to include the name, address, and telephone number of the entity and/or person who conducted the investigation. __________ Check here if a Continuation Form is attached. 19. All Declarants must provide a handwriting sample on the lines below. Write the following statement in your usual handwriting: “I understand that I must use complete candor in answering each question because I seek to become a member of a profession that requires honesty and trustworthiness. I understand that dishonesty and lack of trustworthiness in carrying out responsibilities may result in denial of admission to the bar of Texas.” _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ 10 BLE-1.pdf (10/2010) 20. If you have not enclosed certain required documentation that must be obtained from third parties, you must make a good faith effort to provide that documentation to the Board within thirty (30) days. If applicable, list on a Continuation Form any documentation you have not provided. __________ Check here if a Continuation Form is attached. Before you complete the following Affidavit, verify that you have fully responded to all items, questions, and statements; that you have completed your handwriting sample required in item 19; and that you have completed your Authorization and Release Forms as well as all required Continuation Forms, Civil Litigation Forms, and Criminal History Forms. 11 BLE-1.pdf (10/2010) AFFIDAVIT Before me, a Notary Public, on this day personally appeared _________________________________________, who (Declarant’s Printed Name) after being duly sworn by me, declared: “I have read the instructions and inquiries that constitute the Declaration of Intention to Study Law. No revisions or alterations have been made to the text of any inquiry on this form. I have responded to all inquiries on this form fully and frankly, and all the information contained in my Declaration (including any required Continuation Form, Criminal History Form, Civil Litigation Form, Employment Form, or any other information) is true and correct. All documents that I have provided or will provide to the Board, that are not required to be certified copies, are to the best of my knowledge, true and correct copies of the original documents. “I understand that the purpose of all of the inquiries in this Declaration is to provide to the Board of Law Examiners sufficient information for its investigation as to my present moral character and fitness. I further understand that the fact that the Declaration form inquires about a particular matter does not mean that the matter is conclusive as to my present moral character and fitness. I understand that the Board’s inquiries and investigation will cover matters which may or may not be grounds for finding that I lack the present good moral character and fitness required for admission to the Bar of Texas. “I have read the current version of Rules Governing Admission to the Bar of Texas and the statutes governing the Board of Law Examiners found in Texas Government Code, §82.001 et seq. I understand that, until I am licensed to practice law in the State of Texas, it is my responsibility to read any subsequent amendments to the Rules Governing Admission to the Bar of Texas and to §82.001 et seq., Texas Government Code, regardless of whether such amendments are adopted after the filing of this document. “I declare my intention to study law and to seek admission to the Bar of Texas upon completion of the law study requirement and other requirements imposed by the Rules Governing Admission to the Bar of Texas. I understand that the responses submitted on this Declaration and all attendant forms are submitted under oath, and that failure to respond to any inquiry or to disclose fully and accurately any facts or information called for herein may result in a finding that I do not have the present good moral character and/or fitness required for admission to the Bar of Texas. “I am aware that I am under an on-going obligation to update my responses on my Declaration whenever there is an addition or change to information previously provided to the Board. I will notify the Board, in writing, as soon as practicable, but not later than the filing of my application for admission to the Bar of Texas, of the occurrence giving rise to the need to add or to change information previously provided and will promptly furnish any additional documentation requested by the Board in connection therewith. “I am aware that I have a duty to, and I agree that I will, advise the Board, in writing, of any change of address and telephone number, even if such change is only for the summer months, so that the Board can contact me at any time if the need arises. I affirm that I will keep the Board apprised of my address and telephone number at all times. “I further depose that, having submitted the foregoing declaration using the Board’s web version, no revisions or alterations have been made to the text or questions contained therein; and that if revisions or alterations are made, it is understood by me that the declaration may be denied, or, if granted, may be revoked, and all fees forfeited.” __________________________________________ Signature of Declarant Subscribed and sworn to before me on this __________ day of _______________________ , ______________. (Seal) ___________________________________________ Signature of Notary My Commission expires: ______________________ 12 BLE-1.pdf (10/2010) CIVIL LITIGATION FORM (Use a separate form for each matter requiring a Civil Litigation Form. Make additional copies of this form as needed.) Indicate in the Disposition section whether the matter has been concluded or is still pending. If you are, or were, a plaintiff, you must complete the Form, but you are not required to attach any documentation. If you were a defendant in a matter that has been concluded, attach a legible copy of the docket sheet. If a judgment was rendered against you, attach a legible copy of the judgment and proof of satisfaction, if applicable. Provide an explanation if the judgment has not been satisfied. If the matter resulted in a settlement, provide a summary of the terms as they relate to you and a statement as to whether you adhered to same. If you are a defendant in a matter that is pending, attach a legible copy of the docket sheet and a legible copy of the most recent petition/complaint. Do not leave any line blank. If a line does not apply, enter 'Does not apply' or N/A on that line. NAME: _______________________________________________________________________________________________________ Last First Middle YOUR ROLE IN THIS SUIT: _____ PLAINTIFF _____ DEFENDANT _____ OTHER: _____________________________ (specify role) CAUSE NUMBER (S): __________________________________________________________________________________________ STYLE: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ TITLE OF COURT: ____________________________________________________________________________________________ MAILING ADDRESS OF COURT: ________________________________________________________________________________ ______________________________________________________________________________________________________________ NAME AND ADDRESS OF YOUR LEGAL COUNSEL IN THIS CASE, IF ANY: _________________________________________ ______________________________________________________________________________________________________________ DISPOSITION: ________________________________________________________________________________________________ ______________________________________________________________________________________________________________ SUMMARY OF THE LITIGATION: (Use a Continuation Form for additional space, if necessary.) ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ 13 BLE-1.pdf (10/2010) CRIMINAL HISTORY FORM (Use a separate form for each incident requiring a Criminal History Form. Make additional copies of this form as needed.) Arrest/offense reports: If any of the offenses you describe resulted from an arrest (as opposed to a citation or a ticket) that occurred within five years of the date you sign this Declaration, you are responsible for either providing legible copies of the arrest/offense reports for such offenses, or providing proof that you made a written request, to the appropriate entity, for such reports. You are not required to provide copies of citation or tickets. Court records: If any of the offenses you describe, whether they resulted from an arrest, citation, or ticket, occurred within five years of the date you sign this Declaration, you are responsible for either providing legible copies of all court records for all such offenses, or providing proof that you made a written request, to the appropriate entity, for such court records. NAME: _____________________________________________________________________________________________ Last First Middle Date of Incident: ______________________________________________________________________________________ Location of Incident: __________________________________________________________________________________ City County/State/Country Arresting/Ticketing Agency: ____________________________________________________________________________ Name of Agency ____________________________________________________________________________________________________ Mailing Address City State/Country Zip/Postal Code Detailed Summary of the events and circumstances leading to this arrest, citation, ticket, and/or criminal charge: (Use Continuation Form, if necessary.) ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ CHARGES. For each charge, indicate whether it was a misdemeanor or a felony: Initial Charge(s): _______________________________ _____ Misdemeanor _____ Felony Ultimate Charge (s): _______________________________ _____ Misdemeanor _____ Felony Plea: _______________________________________________________________________________________________ Disposition: (If probation, deferred adjudication, or deferred prosecution, give summary.) ___________________________ ____________________________________________________________________________________________________ Style and Cause Number(s): ____________________________________________________________________________ Title of Court: ________________________________________________________________________________________ Mailing Address of Court: ______________________________________________________________________________ Name and address of your legal counsel in this case, if any: ___________________________________________________ __________________________________________________________________________________________________ 14 BLE-1.pdf (10/2010) CONTINUATION FORM (Use a separate form for each question that requires a Continuation Form. Make additional copies of this form as needed.) For Question No. ________________ NAME: _____________________________________________________________________________________________ Last First Middle ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 15 BLE-1.pdf (10/2010) EMPLOYMENT FORM (Make additional copies of this form as needed.) NAME OF EMPLOYER: _________________________________________________________________________ CURRENT ADDRESS: ___________________________________________________________________________ Street TELEPHONE NUMBER: ________________________ City State DATES EMPLOYED: ______________________________ From (mm/dd/yy) Area Code POSITION HELD: _____________________________ Zip To (mm/dd/yy) NAME OF SUPERVISOR: ___________________________ REASON FOR LEAVING: _________________________________________________________________________ NAME OF EMPLOYER: _________________________________________________________________________ CURRENT ADDRESS: ___________________________________________________________________________ Street TELEPHONE NUMBER: _________________________ City State DATES EMPLOYED: ______________________________ From (mm/dd/yy) Area Code POSITION HELD: _____________________________ Zip To (mm/dd/yy) NAME OF SUPERVISOR: ___________________________ REASON FOR LEAVING: _________________________________________________________________________ NAME OF EMPLOYER: _________________________________________________________________________ CURRENT ADDRESS: ___________________________________________________________________________ Street TELEPHONE NUMBER: _________________________ City State DATES EMPLOYED: ______________________________ From (mm/dd/yy) Area Code POSITION HELD: _____________________________ Zip To (mm/dd/yy) NAME OF SUPERVISOR: ___________________________ REASON FOR LEAVING: _________________________________________________________________________ NAME OF EMPLOYER: _________________________________________________________________________ CURRENT ADDRESS: ___________________________________________________________________________ Street TELEPHONE NUMBER: _________________________ City Zip DATES EMPLOYED: ______________________________ From (mm/dd/yy) Area Code POSITION HELD: _____________________________ State To (mm/dd/yy) NAME OF SUPERVISOR: ___________________________ REASON FOR LEAVING: _________________________________________________________________________ 16 BLE-1.pdf (10/2010) Board of Law Examiners Appointed by the Supreme Court of Texas AUTHORIZATION AND RELEASE I, ________________________________________, born in ___________________________________________ (Declarant’s Printed Name) (City/State/Country) hereby give my consent to the Board of Law Examiners of the State of Texas to conduct an investigation as to my moral character and fitness and to make inquiries and request such information from third parties as, in the sole discretion of the Board, is necessary to such investigation. I further authorize the use of any such information in the course of the Board’s investigation and evaluation of my moral character and fitness. I authorize and request every person, firm, company, corporation, school, employer (past or present), governmental agency, court, association, institution, or other third party having opinions about me or knowledge or control of any information, documents, records (including but not limited to criminal history record information, medical or psychological records), or other data pertaining to me, to reveal, furnish and release to the Board of Law Examiners of the State of Texas, or any of its agents or representatives, any such opinions, knowledge, information, documents, records or other data. Without limiting the previously described authority, I specifically authorize the release of files of any bar association, grievance or other bar committee regarding charges or complaints filed against me, formal or informal, pending or closed, or any other pertinent data, as well as all undergraduate, graduate, or law school records relating to my admission to, and conduct during my enrollment in, such schools. I hereby release, discharge and hold harmless the Board of Law Examiners of the State of Texas, its agents or representatives (including but not limited to expert witnesses or evaluators consulted or used by the Board or its staff in the course of its investigation), and any person, firm, company, corporation, school, employer (past or present), governmental agency, court, association, institution, or other third party, and their agents, from any and all liability of every nature and kind arising out of the furnishing, inspection, and use of such opinions, knowledge, documents, records or other data. Notwithstanding any statement herein to the contrary, this Authorization and Release shall operate to agree to the release of only those mental health records relating to the following: (a) my being diagnosed with bi-polar disorder, schizophrenia, paranoia, or any other psychotic disorder, and any treatment therefor, within the ten (10) years immediately preceding the filing of my Declaration with the Board of Law Examiners; and (b) my admission to a hospital or other facility for the treatment of bi-polar disorder, schizophrenia, paranoia, or any other psychotic disorder, since attaining the age of eighteen or within the ten (10) years immediately preceding the filing of my Declaration, whichever period is shorter. This limitation, however, does not apply to records relating to chemical dependency. ___________________________________________ Signature of Declarant Subscribed and sworn to before me on this __________ day of _______________________ , ______________. (Seal) ___________________________________________ Signature of Notary My Commission expires: ______________________ 17 BLE-1.pdf (10/2010) Board of Law Examiners Appointed by the Supreme Court of Texas AUTHORIZATION AND RELEASE I, ________________________________________, born in ___________________________________________, (Declarant’s Printed Name) (City / State /Country) hereby give my consent to the Board of Law Examiners of the State of Texas to conduct an investigation as to my moral character and fitness and to make inquiries and request such information from third parties as, in the sole discretion of the Board, is necessary to such investigation. I further authorize the use of any such information in the course of the Board’s investigation and evaluation of my moral character and fitness. I authorize and request every person, firm, company, corporation, school, employer (past or present), governmental agency, court, association, institution, or other third party having opinions about me or knowledge or control of any information, documents, records (including but not limited to criminal history record information, medical or psychological records), or other data pertaining to me, to reveal, furnish and release to the Board of Law Examiners of the State of Texas, or any of its agents or representatives, any such opinions, knowledge, information, documents, records or other data. Without limiting the previously described authority, I specifically authorize the release of files of any bar association, grievance or other bar committee regarding charges or complaints filed against me, formal or informal, pending or closed, or any other pertinent data, as well as all undergraduate, graduate, or law school records relating to my admission to, and conduct during my enrollment in, such schools. I hereby release, discharge and hold harmless the Board of Law Examiners of the State of Texas, its agents or representatives (including but not limited to expert witnesses or evaluators consulted or used by the Board or its staff in the course of its investigation), and any person, firm, company, corporation, school, employer (past or present), governmental agency, court, association, institution, or other third party, and their agents, from any and all liability of every nature and kind arising out of the furnishing, inspection, and use of such opinions, knowledge, documents, records or other data. Notwithstanding any statement herein to the contrary, this Authorization and Release shall operate to agree to the release of only those mental health records relating to the following: (a) my being diagnosed with bi-polar disorder, schizophrenia, paranoia, or any other psychotic disorder, and any treatment therefor, within the ten (10) years immediately preceding the filing of my Declaration with the Board of Law Examiners; and (b) my admission to a hospital or other facility for the treatment of bi-polar disorder, schizophrenia, paranoia, or any other psychotic disorder, since attaining the age of eighteen or within the ten (10) years immediately preceding the filing of my Declaration, whichever period is shorter. This limitation, however, does not apply to records relating to chemical dependency. ___________________________________________ Signature of Declarant Subscribed and sworn to before me on this __________ day of _______________________ , ______________. (Seal) ___________________________________________ Signature of Notary My Commission expires: ______________________ 18 BLE-1.pdf (10/2010) CHANGE OF ADDRESS NOTIFICATION Use this page to notify the Board of your address change