APPLICATION FOR MEMBERSHIP ON THE CRIMINAL JUSTICE ACT DEFENSE PANEL (Prior applicants to the Panel should see the note on the following page.) UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF CALIFORNIA APPLICATIONS MUST BE POSTMARKED BY MAY 2, 2011 American LegalNet, Inc. www.FormsWorkFlow.com NORTHERN DISTRICT OF CALIFORNIA CRIMINAL JUSTICE ACT PANEL APPLICATION FORM NOTE: If you applied for membership in either of the previous three years and wish to reactivate your application, you must send a letter to the appropriate address (San Francisco or San Jose) stating that you want to be considered for this year's panel and either (1) there are no changes to the information you provided in your most recent application or (2) the information you provided in your most recent application has changed and specifying any such change(s). It is not necessary to submit a new application, although you may do so in lieu of submitting a letter. If you choose to reactivate your application by letter, you must submit the same number of copies as is required for a new application. (See instructions below.) To review the content of your earlier application, you may contact Ruben Deang, Jr. of the San Francisco Federal Public Defender’s Office at: ruben_deang@fd.org. INSTRUCTIONS The application is an interactive form and is to be completed on a word processor. The Regulations for Implementation of the Northern District's Criminal Justice Act Plan are attached to the end of the application. Please detach and retain the regulations for your future reference. Applications for Appellate Panel Mail or Deliver Original and 4 copies (including 4 copies of the writing sample) to the address that follows for the San Francisco/Oakland Trial Panel. If you are applying for membership on a trial panel and on the appellate panel, please send enough copies for both (i.e., San Francisco/Oakland Panel and Appellate Panel would require a total of Original and 14 copies). Applications for San Francisco/Oakland Trial Panel This Panel only accepts applications from attorneys whose principal place of business is located within the San Francisco/Oakland venue of the Northern District, i.e., the counties of Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, and Sonoma. Mail or Deliver Original and 10 copies (including 10 copies of the writing sample) to: CJA Panel Selection Committee Attn: Ruben P. Deang, Jr. Federal Public Defender’s Office 450 Golden Gate Avenue, Box 36106 San Francisco, California 94102 American LegalNet, Inc. www.FormsWorkFlow.com Applications for San Jose Panel This Panel only accepts applications from attorneys whose principal place of business is located within the San Jose venue of the Northern District, i.e., the counties of Santa Clara, Santa Cruz, Monterey, and San Benito. Mail or Deliver Original and 3 copies (including 3 copies of the writing sample) to: CJA Panel Selection Committee Attn: Susan Sbragia Federal Public Defender’s Office 160 West Santa Clara Avenue, Suite 575 San Jose, California 95113 American LegalNet, Inc. www.FormsWorkFlow.com Name: _________________________________________ State Bar No.: _________________ Applying for (you may apply for more than one panel): Trial Panel (San Francisco/Oakland Division) Trial Panel (San Jose Division) Appellate Panel If you applied for membership in the San Francisco/Oakland Division Trial Panel, please mark if you are willing to accept occasional appointments in the San Jose Division along with your San Francisco/Oakland appointments. _____ Yes No APPLICATION FOR MEMBERSHIP ON THE CRIMINAL JUSTICE ACT DEFENSE PANEL UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF CALIFORNIA APPLICATIONS MUST BE POSTMARKED BY MAY 2, 2011 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION A. Biographical Information 1. Name_________________________________________________________________________ 2. Business address ________________________________________________________________ Name ______________________________________________________________________________ Street ______________________________________________________________________________ City, State, and Zip Code ______________________________________________________________________________ Business telephone Facsimile Number E-mail Address B. Present Employment or Affiliation 1 Name of firm or agency _________________________________________________________ 2. Address ______________________________________________________________________ Street _____________________________________________________________________________ City, State and Zip Code 3. ______________________________________________________________________________ Telephone 4. Your title or position________________________________________________________________ 5. Your supervisor's or managing partner's name (if any) _________________________________________________________________________________ 6. Your supervisor's title or position ______________________________________________________ 7. Dates of employment or affiliation _____________________________________________________ 8. Give a synopsis of this position including nature of practice and types of matters accounting for most of your time. American LegalNet, Inc. www.FormsWorkFlow.com C. Past Legal Employment or Affiliations Prior Positions (List legal experience for last fifteen years, excluding your current position) Please use the following format for each employer. 1. Employer, firm or agency_____________________________________________________ Address ___________________________________________________________________ Telephone _________________________________________________________________ Supervisor or managing partner ________________________________________________ Title or position(s) you held (e.g., associate, partner) _______________________________ __________________________________________________________________________ Dates of employment or affiliation______________________________________________ Duties American LegalNet, Inc. www.FormsWorkFlow.com 2. If you were employed as a prosecutor or public defender and that information was not covered in the preceding pages, list the dates, office(s), address(es), supervisor(s) and type of practice in which you were engaged in that position. 3. Summarize your criminal law experience and practice, indicating the number of felony and misdemeanor cases tried, the number of appeals handled, and the types of non-trial matters, e.g., extradition, habeas corpus, in which you have been involved. American LegalNet, Inc. www.FormsWorkFlow.com D. Description of Legal Practice 1. Estimate the percentages of your total time in legal work during the last seven years that concerned: Federal civil law matters: Federal criminal law matters: % State civil law matters: % State criminal law matters: % Other1: 2. % % Estimate the percentages of your total time spent in legal work during the last seven years that were: In court: % Litigation, but not in court: % Negotiations/Mediation: % Advising and counseling clients: % Legal research and writing: % Supervising the legal work of others: % Legal Education: % Other matters2: % 1 If any single aspect of your legal work occupied more than 10%, please list it separately with a corresponding percentage, rather than in the "Other" category. 2 E.g., administration, business development, firm management, etc. American LegalNet, Inc. www.FormsWorkFlow.com E. Part I. Trial Panel (If you are only applying to the appellate panel, you do not need to submit this information.) Provide the following information for five federal or state felony jury trials in which you were involved. It is preferred that you describe your more significant and recent cases. In the absence of five trials, list complex criminal or civil matters which resolved other than by trial. Please use the following format for each trial. It is important that you provide the information in this format. Case name __________________________________________________________________ Court, case citation number (if any) and year _______________________________________ Presiding judge ______________________________________________________________ Nature of case _______________________________________________________________ Your role in case______________________________________________________________ Results of your activities in this case Co-counsel (list all) _____________________________________________________________ Name _____________________________________________________________________________ Address _____________________________________________________________________________ City/State/Zip Code Phone Opposing counsel (list all) ________________________________________________________ Name _____________________________________________________________________________ Address _____________________________________________________________________________ City/State/Zip Code Phone American LegalNet, Inc. www.FormsWorkFlow.com E. Part II. Appellate Panel (If you are only applying for the trial panel, it is not necessary for you to complete this section.) Provide the following information for ten federal or state criminal appeals in which you were involved. It is preferred that you describe your more significant and recent cases. In place of ten appeals, you may list criminal trials, complex criminal matters settled short of trial, or habeas corpus proceedings. Please use the following format for each appeal. It is important that you provide the information in this format. Case name ____________________________________________________________________ Court, case citation number (if any) and year _________________________________________ Panel of judges or presiding judge _________________________________________________ Nature of case _________________________________________________________________ Your role in case _______________________________________________________________ Results of your activities in this case Co-counsel (list all)_____________________________________________________________ Name _____________________________________________________________________________ Address _____________________________________________________________________________ City/State/Zip Code Phone Opposing counsel (list all) _______________________________________________________ Name _____________________________________________________________________________ Street _____________________________________________________________________________ City/State/Zip Code Phone American LegalNet, Inc. www.FormsWorkFlow.com F. Prior Panel Experience 1. If you are a past or present member of this district's Criminal Justice Act Trial or Appeals Panel, list dates of panel membership. 2. For any other criminal indigent panel of which you are or were a member, please list the panel, the dates of membership, the class of criminal case you were qualified to try, if any, and the name, address and telephone number of the panel supervisor or administrator. G. Court Admission Date of Admission to: Northern District of California: ______________________________________________________ Ninth Circuit Court of Appeals: ______________________________________________________ United States Supreme Court: ________________________________________________________ State Bar of California: _____________________________________________________________ State Bar Number: __________________________________________________________________ List state court bars other than California to which you are presently admitted to practice and the year of admission. Provide the addresses of the administrative offices of these organizations. State bar __________________________________________________________________________ Year admitted _________________________________________________________Reg#_________ Address____________________________________________________________________________ Street ___________________________________________________________________________________ City/State/Zip Code State bar __________________________________________________________________________ Year admitted _________________________________________________________Reg#_________ Address____________________________________________________________________________ Street ___________________________________________________________________________________ City/State/Zip Code American LegalNet, Inc. www.FormsWorkFlow.com State bar __________________________________________________________________________ Year admitted _________________________________________________________Reg#_________ Address____________________________________________________________________________ Street ___________________________________________________________________________________ City/State/Zip Code H. Education 1. Undergraduate institution Degree(s) received & year(s) awarded Major field(s) of study 2. Law school name _______________________________________________________________ Law school address _____________________________________________________________ Street _____________________________________________________________________________ City/State/Zip Code Degree received & year awarded___________________________________________________ Describe any honors, awards, law review membership, or other law school activities or achievements. 3. Other undergraduate or graduate education received ___________________________________ Institution attended _____________________________________________________________ Course of study ________________________________________________________________ Degree received (if any) & year awarded ____________________________________________ 4. List any specialized legal expertise or experience (e.g., immigration, tax, intellectualproperty). 5. List all foreign languages in which you are fluent. American LegalNet, Inc. www.FormsWorkFlow.com 6. Are you and/or your staff proficient the use of: Excel or other billing software? Document indexing/organization/database software? Trial presentation software? Web-hosted document repositories? Yes Yes Yes Yes No No No No Please describe your experience and skills with these, listing specific applications with which you've worked. ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com I. References Please list information for three persons who are well-acquainted with your work and with your qualifications to be a panel member. 1. Name _____________________________________________________________________ Title ______________________________________________________________________ Street______________________________________________________________________ City/State/Zip_______________________________________________________________ Phone_____________________________________________________________________ Relationship________________________________________________________________ Period of acquaintance________________________________________________________ 2. Name _____________________________________________________________________ Title ______________________________________________________________________ Street______________________________________________________________________ City/State/Zip_______________________________________________________________ Phone_____________________________________________________________________ Relationship________________________________________________________________ Period of acquaintance________________________________________________________ 3. Name _____________________________________________________________________ Title ______________________________________________________________________ Street______________________________________________________________________ City/State/Zip_______________________________________________________________ Phone_____________________________________________________________________ Relationship________________________________________________________________ Period of acquaintance________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com J. Additional Questions Respond to each of the following inquiries where applicable. Indicate on an attachment sheet which items you are replying to and indicate which questions, if any, are inapplicable. 1. 2. Has your license or right to practice before any state, court agency, or other tribunal ever been denied, revoked or suspended? If so, describe the facts and circumstances fully on an attached sheet. Yes No Have you ever been censured, reprimanded, adjudged or held in contempt or otherwise disciplined by any judge, court, agency or tribunal? If so, describe the facts and circumstances fully on an attached sheet. Yes No 3. Has your professional conduct or ability been the subject of comment, favorable or unfavorable, in a written opinion of any judge, court, or other tribunal? If so, attach a copy of the opinion and state any facts and circumstances you feel appropriate. Use attached sheet. Yes No 4. Have you ever been the subject of any complaint filed with, or made to any attorney disciplinary body or any bar association or committee thereof? If so, state fully the facts and circumstances and the disposition of the matters on an attached sheet. Yes No 5. Have you been sued by a client? If so, state fully on an attached sheet the facts and circumstances, the court and case number, and the disposition of the matter. Yes No 6. Please supply any additional information you wish to support your application. 7. Please submit a copy of a recent brief or memorandum of points and authorities you have authored. American LegalNet, Inc. www.FormsWorkFlow.com I understand that attorneys are selected to serve on the panel at the pleasure of the Court o represent indigent defendants; that this application only provides information for the use of the Court to select members of the panel and does not create entitlement for participation on the panel or appointment to cases; and that panel attorneys are subject to removal by the Court. I understand and agree that representation of an indigent client upon appointment by the Court is a professional privilege and duty, subject to the Court's discretion, and even if I am placed on the panel, I have no "right to appointment" to represent any indigent client. I agree to abide by the Regulations for the Implementation of the Northern District's Criminal Justice Act Plan. I understand that failure to provide true and correct information in answer to any of the questions on this form will be grounds for denial of panel membership or removal from service on the panel. I certify that I have read and understand the above and agree to it. Dated: __________________ ____________________________________ Signature American LegalNet, Inc. www.FormsWorkFlow.com Northern District of California Criminal Justice Act Panel Application Form Office of the Federal Public Defender P.O. Box 36106 San Francisco, CA 94102 (415) 436-7700 PROFESSIONAL EXPERIENCE INQUIRY AUTHORIZATION AND WAIVER FORM I hereby authorize the administrators of the disciplinary and inquiry bodies of any court, bar or other association to disclose to the Criminal Justice Act Administration Committee of the Northern District of California all information contained in the files of such bodies concerning my present professional status, all complaints which have been made against me, together with the disposition thereof. I expressly waive whatever right I may have to confidentiality of the foregoing information. I also hereby authorize the custodian of any records or information related to my application for the Criminal Justice Act Panel of the Northern District of California to permit the examination or receipt of such records and/or information by anyone designated by the Criminal Justice Act Administration Committee. _____________________________________ Print or Type Name _______________________________ Signature _____________________________________ Social Security Number _______________________________ Date Signed American LegalNet, Inc. www.FormsWorkFlow.com Northern District of California Criminal Justice Act Panel Application Form Office of the Federal Public Defender P.O. Box 36106 San Francisco, CA 94102 (415) 436-7700 STATE BAR OF CALIFORNIA RELEASE OF ALL CLAIMS FORM I hereby release, discharge and exonerate the State Bar of California, its agents and representatives, and any person so furnishing information from any and all liability of every nature and kind arising out of the furnishing or inspection of such documents, records, or the information or the investigation made by the State Bar of California. The undersigned further waives all rights or benefits which the undersigned now has or in the future may have under the terms of § 1542 of the Civil Code of the State of California, which said section reads as follows: "A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executive the release, which if know by him must have materially affected his settlement with the debtor." _______________________________________ Print or Type Name ____________________________ Signature _______________________________________ Social Security Number ____________________________ Date Signed American LegalNet, Inc. www.FormsWorkFlow.com ADDENDUM TO APPLICATION FOR MEMBERSHIP ON CJA PANEL, U.S. DISTRICT COURT, NORTHERN DISTRICT OF CALIFORNIA __________________________, a current or prospective member of the CJA Panel for the U.S. District Court, Northern District of California, agrees to the following: 1. Any voucher submitted for payment of fees and expenses for work performed in a case assigned to me as a member of the CJA Panel may be reviewed by the Fee Review Committee for the U.S. District Court, Northern District of California. 2. I understand that neither the Fee Review Committee’s recommendation nor the final decision of the court is subject to review. Dated: _______________ _________________________________ Signature of Panel Member/Applicant American LegalNet, Inc. www.FormsWorkFlow.com