IN THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF DELAWARE FEDERAL CIVIL PANEL Name: Last, First, MI. (please print) Law Firm: Mailing Address: E-Mail Address: Telephone: DE Bar ID#: Willing to accept: Ext.: Date Admitted USDC Bar: G Prisoner civil rights cases G Employment discrimination cases G Other civil cases G G Willing to serve as Co-Coordinator? Willing to help with educational programs for Panel members? Languages: (other than English) G Spoken G Spoken G Spoken G Written G Written G Written I agree to be a member of the Federal Civil Panel as set out in the Court's Standing Order, dated May 25, 1999. Signature G Please provide orientation materials. --------------------------------------------------------------------Please return completed form to: OFFICE OF THE CLERK UNITED STATES DISTRICT COURT 844 N KING STREET UNIT 18 WILMINGTON DE 19801-3570 ATTN: Ronald B. Eberhard fedcivpa\signupform.wpd Date American LegalNet, Inc. www.FormsWorkFlow.com