Page 1 of 3APPLICATION FOR APPOINTMENT AS A MAGISTRATE Pursuant to C.G.S. 247 51-193l JD-ES-268 Rev. 7-12STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.govInstructions 1.Answer all questions completely. If you needadditional space to answer one or more questions, attach additional pages referencing the question(s) being answered. 2.Obtain and submit a Certificate of Good Standing(see http://www.jud.ct.gov/CBEC/faq3.htm#G5). 3.Obtain and submit 3 letters of reference.4.Forward the completed application to:Magistrate Matters Superior Court Operations 225 Spring Street Wethersfield, CT 06109 or e-mail to: Magistrate.Matters@jud.ct.gov ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommo-dation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. Name: Juris number: Date:General1.State your full name. (If you have ever been known by any other name, state the name and reason for change.)2.Contact information:a.State your office and home address, telephone numbers, and fax numbers. (Include name of law firm, if applicable.)b.State your email address on file with the Judicial Branch's E-services. 3.On what date were you admitted to practice law in the State of Connecticut?4.Are you an attorney in good standing in the State of Connecticut? (Obtain and submit a Certificate of Good Standing aspart of this application. See http://www.jud.ct.gov/CBEC/faq3.htm#G5.) Yes No5.List all other courts in which you are presently admitted to practice, including the dates of admission in each case. Give thesame information for administrative bodies having special admission requirements.6.Specify the Judicial District(s) and specialized dockets for which you wish to be appointed.Judicial Districts: Ansonia-Milford at Milford and at Derby Danbury Fairfield Hartford at Hartford and at Manchester Litchfield Middlesex New Britain New Haven at New Haven and at Meriden New London at New London and at Norwich Stamford-Norwalk at Stamford and at Norwalk Tolland Waterbury WindhamSpecialized Dockets: Centralized Infractions Bureau Centralized Small Claims7.Do you, any member of a law firm with which you are associated, or your employer have any matter(s) pending orrepresent any party with any matter(s) pending:a.That can be heard by a magistrate?b.In a Judicial District listed in #6 above? (If yes, identify the Judicial District(s).)8.Describe your experience that demonstrates you can perform the duties of a magistrate. (Please reference any services asa small claims commissioner, fact-finder, arbitrator, attorney trial referee, special master, or any similar capacity.) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3JD-ES-268 Rev. 7-12 Date: Name: Juris number:Conduct1.Have you ever been found in violation of the Connecticut Rules of Professional Conduct or their equivalent in anotherjurisdiction? If so, state the particulars.2.Have you ever been disbarred in any jurisdiction? If so, provide the details and date of readmission.3.Are you aware of any complaints concerning your conduct being made to a person within the judicial system, other thanthe Statewide Grievance Committee, such as to any administrative judge or the Chief Court Administrator? If so, explainthe complaint and the disposition of the complaint.4.Have you ever been arrested? If yes, give circumstances.5.Have you been convicted of violating any federal, state, county, or municipal law, regulation, or ordinance? If so, give thedetails.6.Have you ever filed for bankruptcy or had bankruptcy proceedings initiated against you? If so, explain.7.Do you presently have any non-current unpaid tax or Client Security Fund fee obligations? If so, explain.Current Employment1.If you are not actively engaged in the practice of law at the present time, state the details of your current employment.2.If you are or have previously been engaged in the practice of law, describe the general character of your practice. Indicatethe nature of your typical clients and whether you have practiced in any specialty area. If the nature of your practice hasbeen substantially different at any time, give the details, including the nature of your earlier practice.3.Are you employed by the State of Connecticut in any position? If yes, explain.4.Do you contract with the State of Connecticut to provide services? If yes, explain.Civic, Professional And Other Associations1.Describe any pro bono or community service activities in which you are or have been engaged including any connectionsto civic, charitable, or social organizations. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3JD-ES-268 Rev. 7-12 Date: Name: Juris number:2.Do you currently belong or have you belonged to any organization that discriminates on the basis of race, sex, sexualorientation, disability, ancestry, or religion through either formal membership requirements or the practical implementationof membership policies? If so, state the organization and the dates of membership.Current Magistrates1.Provide a list of cases since the date of your last appointment in which an appeal or writ of error was taken to the AppellateCourt or Supreme Court from a decision rendered by you as a magistrate. Provide the citations to the Appellate and Supreme Court opinions and briefly state the central issue and the result of the appeal.2.Have you ever been asked to disqualify yourself in your role as a magistrate and you have refused to do so? If so, explain.All ApplicantsIs there anything not otherwise disclosed above concerning you or any member of your immediate family that (i) would be embarrassing with respect to the office of magistrate should that information be publicized or (ii) could adversely affect your ability to continue to serve as a magistrate? If so, explain.Required Attachments 1.Authorization for Release of Information - References and Criminal Record Check. 2.Your current r351sum351.3.Certificate of Good Standing. See http://www.jud.ct.gov/CBEC/faq3.htm#G5. 4.Three letters of reference. At least one letter should speak to your ability to serve as a magistrate.I apply to be appointed for a three-year term as a magistrate in accordance with Section 51-193l of the Connecticut General Statutes. I am a Commissioner of the Superior Court of Connecticut and have been admitted to practice in this state for at least five years. If appointed a magistrate, I will 002002002 Date SignedSigned (Applicant) American LegalNet, Inc. www.FormsWorkFlow.com