Page 1 of 7APPLICATION FOR AUTHORITY TO CERTIFY LAWYERS AS SPECIALISTS JD-ES-63 Rev. 1-19STATE OF CONNECTICUT JUDICIAL BRANCH www.jud.ct.govInstructions ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA.1.Complete the form for new or renewal applications.2.Include a copy of the application form that lawyersseeking to be certified as specialists are required tocomplete to become so certified;3.Include a copy of each examination that lawyersseeking to be certified as specialists are required totake to become so certified;4.Include a copy of the written or published standards orqualifications that lawyers seeking to be certified as specialistsare required to meet to become so certified; and5.Send one completed application and accompanying materials to:Chair of the Legal Specialization Screening Committee, c/oDirector of Legal Services, Judicial Branch, State of Connecticut,P.O. Box 150474, Hartford, Connecticut 06115-0474,and one electronic copy of the same to LSSC@jud.ct.gov .Applicant 227 General Information (Select one): New Application Renewal Application Full legal name of applicant Date Mailing address of applicant E-mail address of applicant Website address of applicant Telephone number of applicant Name of person to contact regarding application Telephone number of contact Mailing address of contact E-mail address of contact State whether the applicant is a (choose one and complete the applicable information section set out below) Sole Proprietorship Partnership Corporation Voluntary AssociationSole Proprietorship Information Date proprietorship was formed City or town and state in which it is registered as doing business Name of proprietor Telephone number of proprietor Address of proprietor1.State the name and address of each bar to which the sole proprietor and all persons directly involved in the process ofcertifying applicants, including, but not limited to, accepting and evaluating applications, devising, administering andgrading examinations, and certifying and recertifying, is or has been admitted to practice law.2.State whether the sole proprietor or anyone identified in 1 above has been disciplined by the authority that admitted suchperson to practice law and, if so, the name and address of such authority, the docket number or other means of identifyingthe case, and the details thereof as to each person so disciplined.3.State whether a judgment of a court of competent jurisdiction has entered against the sole proprietor or anyone identified in1 above for negligence or other misconduct in the practice of law and, if so, the name and address of such court, thedocket number or other means of identifying the case, and the details thereof as to each person so adjudged. American LegalNet, Inc. www.FormsWorkFlow.com JD-ES-63 Rev. 1-19Page 2 of 74.State whether as to the sole proprietor or anyone identified in 1 above there is now pending: (a) any disciplinary matterbefore the authority that admitted such person to practice law and, if so, the name and address of such authority, thedocket number or other means of identifying the case, and the details thereof as to each person subject to such pendingdisciplinary action; and (b) any lawsuit in a court of competent jurisdiction for negligence or other misconduct in the practiceof law and, if so, the name and address of such court, the docket number or other means of identifying the case and thedetails thereof as to each person subject to such pending legal action.Partnership Information Date partnership was formed City or town and state in which it is registered as doing business or carrying on its activities1.State the name and address of each partner.2.State the name and address of each bar to which each partner and all persons directly involved in the process of certifyingapplicants, including, but not limited to, accepting and evaluating applications, devising, administering and gradingexaminations, and certifying and recertifying, is or has been admitted to practice law.3.State whether any partner or anyone identified in 2 above has been disciplined by the authority that admitted such personto practice law and, if so, the name and address of such authority, the docket number or other means of identifying thecase, and the details thereof as to each person so disciplined.4.State whether a judgment of a court of competent jurisdiction has entered against any partner or anyone identified in 2above for negligence or other misconduct in the practice of law and, if so, the name and address of such court, the docketnumber or other means of identifying the case, and the details thereof as to each person so adjudged.5.State whether as to any partner or anyone identified in 2 above there is now pending: (a) any disciplinary matter before theauthority that admitted such person to practice law and, if so, the name and address of such authority, the docket numberor other means of identifying the case, and the details thereof as to each person subject to such pending disciplinaryaction; and (b) any lawsuit in a court of competent jurisdiction for negligence or other misconduct in the practice of law andif so, the name and address of such court, the docket number or other means of identifying the case, and the detailsthereof as to each person subject to such pending legal action.Corporation Information Date corporation was formed State in which the corporation was incorporated Each state in which the corporation is licensed or registered to do business Corporation is a (choose one) Is the corporation a nonprofit corporation Stock Corporation Nonstock Corporation Yes No1.State the name and address of each officer of the corporation.2.State the name and address of each director of the corporation. American LegalNet, Inc. www.FormsWorkFlow.com JD-ES-63 Rev. 1-19Page 3 of 73.State the name and address of each shareholder of the corporation.4.State the name and address of each member of the corporation.5.State the name and address of each bar to which officers and directors of the corporation, and all persons involved in theprocess of certifying applicants, including, but not limited to, accepting and evaluating applications, devising, administeringand grading examinations, and certifying and recertifying, is or has been admitted to practice law.6.State whether any officer, director, or anyone identified in 5 above has been disciplined by the authority that admitted suchperson to practice law and, if so, the name and address of such authority, the docket number or other means of identifyingthe case, and the details thereof as to each person so disciplined.7.State whether a judgment of a court of competent jurisdiction has entered against any officer, director, or anyone identifiedin 5 above for negligence or other misconduct in the practice of law and, if so, the name and address of such court, thedocket number or other means of identifying the case, and the details thereof as to each person so adjudged.8.State whether as to any officer, director, or anyone identified in 5 above there is now pending: (a) any disciplinary matterbefore the authority that admitted such person to practice law and, if so, the name and address of such authority, thedocket number or other means of identifying the case, and the details thereof as to each person subject to such pendingdisciplinary action; and (b) any lawsuit in a court of competent jurisdiction for negligence or other misconduct in the practiceof law and, if so, the name and address of such court, the docket number or other means of identifying the case, and thedetails thereof as to each person subject to such pending legal action.Voluntary Association Information Date association was formed City or town and state in which it is registered as doing business or carrying on its activities1.State the name and address of each officer of the association.2.State the name and address of each director of the association.3.State the name and address of each bar