QUESTIONNAIRE AND APPLICATION FOR MEMBERSHIP IN THE CRIMINAL JUSTICE ACT PANEL FOR THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF FLORIDA The following Questionnaire and Application is to be completed by attorneys requesting to represent defendants under the provisions of the Criminal Justice Act in the United States District Court for the Middle District of Florida: THE APPLICANT IS HEREWITH APPLYING FOR APPOINTMENT AS A CJA PANEL ATTORNEY. 1. Name: FL Bar # Firm Name: Office Address: E-Mail Address: @ Office Phone: Fax Number: Home Phone: 2. Education and Bar Admissions: Graduated from School of Law. Year: Admitted to practice in the State of Florida on: Admitted to practice in the United States District Court for the Middle District of Florida on: Admitted to practice in the United States Court of Appeals for the Eleventh Circuit on: Admitted to practice in the United States Supreme Court on: Application for Membership in Criminal Justice Act Revised: April 15, 2009 Middle District of Florida Page 1 of 7 American LegalNet, Inc. www.FormsWorkflow.com Others: Jurisdiction or Court Location Date Have you attended a continuing legal education seminar on the topic of the Federal Sentencing Guidelines, and their application, within the twelve months prior to this application? If so, have you certified your compliance with this requirement with the Federal Public Defender? Yes No Have you attended and completed a continuing legal education seminar on federal court criminal practice within the twelve months prior to this application? If so, have you certified your compliance with this requirement with the Federal Public Defender? Yes No Alternatively, have you reviewed the video presentation concerning criminal practice in the Middle District of Florida (which is on file in the Federal Public Defender Office in each division of this District) within the twelve months prior to this application? Yes No Have you participated as counsel of record, either as prosecutor or defense attorney, in at least one criminal jury trial in any federal court? Yes No If not, have you participated in the District’s “second chair” counsel program? If so, please attach to this application a letter from the member of the division’s “CJA Mentor Panel” verifying that you have completed the program. Yes Application for Membership in Criminal Justice Act Revised: April 15, 2009 No Middle District of Florida Page 2 of 7 American LegalNet, Inc. www.FormsWorkflow.com Are you Board Certified in any area of law? Yes No If so, in what state(s) are you Board certified? If so, are you Board Certified in (check appropriate box): Criminal Trial Civil Trial 3. Appellate Other Disciplinary Actions: Have you ever been disciplined by a court or by The Florida Bar or any other state agency regulating attorneys? Yes No Are you the subject of any pending disciplinary action by the Bar of any jurisdiction or by any Court? Yes No If so, please explain in detail on a separate sheet of paper bearing your name and address what the discipline was and the nature of the conduct that led to the disciplinary action. 4. Practice Background (give dates by years): Served as federal defender to Served as state defender to Served as federal prosecutor to Served as state prosecutor to Served in private practice to Served as a Law Clerk to Other: (please describe) Application for Membership in Criminal Justice Act Revised: April 15, 2009 to Middle District of Florida Page 3 of 7 American LegalNet, Inc. www.FormsWorkflow.com 5. Have you at any time been a member of the CJA Panel for this Court? Yes For any other Court? (Please give court title) No Yes No If so, please give names and dates: 5a. Have you ever been removed from this or any other court-appointed attorney panel for disciplinary reasons? ___________ If yes, please explain on a separate sheet. 6. Trial Experience: Approximately how many criminal cases have you tried to verdict? United States District Court: Florida State Court: Other State Court: Approximately how many pleas and sentencings have you handled in federal district court? 6a. Appellate Experience: Approximately how many appellate briefs have you filed in the last five years? United States Circuit Court: United States Supreme Court: Florida Court of Appeals: Florida Supreme Court: Other State Courts: How many oral arguments have you participated in over the last five years? United States Circuit Court: United States Supreme Court: Florida Court of Appeals: Application for Membership in Criminal Justice Act Revised: April 15, 2009 Middle District of Florida Page 4 of 7 American LegalNet, Inc. www.FormsWorkflow.com 6b. Please briefly describe your amount of experience with federal habeas corpus proceedings: 6c. Please list the most significant appellate matter you have handled including the case name and number, whether oral argument was granted and the disposition of the case. If you are applying for appointment to APPEALS only, you MUST SUBMIT A WRITING SAMPLE WITH THE APPLICATION. 6d. Please list the last three trials that you have had. (attach additional sheet if necessary): Describe the type of case and the name of the Judge. Judge Court* Case Name & Number Date of Trial * If a state court trial, please identify the county. If a federal trial outside the Middle District of Florida, please identify the district. 7. List your Continuing Legal Education (CLE) experience as a participant or lecturer in a criminal or trial advocacy program within the last three years. 8. Please briefly describe any other activity or experience which you have had which bears on your qualification to serve as CJA counsel (i.e., other teaching, bar activities, writing). Application for Membership in Criminal Justice Act Revised: April 15, 2009 Middle District of Florida Page 5 of 7 American LegalNet, Inc. www.FormsWorkflow.com 9. Describe briefly the nature of your present practice: 10. Are you fluent in any foreign languages? Yes No Which ones? 11. It is likely that most appointment will be made to CJA lawyers who will rotate “duty” weeks in magistrates’ court. Would you, as one of the duty attorney’s for a given week, be able to be in court within two hours of notification by the appointing judge’s chambers? Yes 12. In which of the following categories of cases will you accept appointment (check boxes): A. 0 - 12 trial days B. 13. No 13 or more trial days Are you willing to handle “cold record” appeals (appeals from trials in which you were not trial counsel)? Yes 14. No Are you willing to handle habeas corpus cases? Yes No It is your responsibility to notify the Federal Public Defender, in writing, if any of the above information changes. I HEREBY CERTIFY that the aforesaid information is true and correct and that I have carefully read the provisions of 18 U.S.C. §3006A(d) and (e). I request that I be considered for appointment to the panel for representation of defendants under the Plan approved in accordance with the Criminal Justice Act of 1964, as amended by the CJA Revision of 1986. Date: Signature: CHECK BOX OF DIVISION PANEL YOU WANT TO SERVE: FT MYERS JACKSONVILLE OCALA ORLANDO TAMPA MAIL APPLICATION ONLY TO THE DIVISION IN WHICH YOU WISH TO BE A MEMBER Application for Membership in Criminal Justice Act Revised: April 15, 2009 Middle District of Florida Page 6 of 7 American LegalNet, Inc. www.FormsWorkflow.com RETURN YOUR ORIGINAL APPLICATION, THE NUMBER OF COPIES SPECIFIED AND ANY OTHER ATTACHMENTS TO EACH DIVISION IN WHICH YOU WISH TO SERVE AT THE ADDRESSES LISTED BELOW USDC Clerk’s Office Jacksonville Division 300 North Hogan Street - Rm 5-304 Jacksonville, FL 32202 Attn: Magistrate Judge Thomas E. Morris send original and one copy USDC Clerk’s Office Ocala Division 207 NW Second Street Ocala, FL 34475 Attn: Magistrate Judge Gary R. Jones send original only USDC Clerk’s Office Tampa Division 801 North Florida Avenue Tampa, FL 33602-3800 Attn: Magistrate Judge Mark A. Pizzo send original and one copy USDC Clerk’s Office Fort Myers Division 2110 First Street, Room 2-194 Fort Myers, FL 33901 Attn: Magistrate Judge Douglas N. Frazier send original only USDC Clerk’s Office Orlando Division Attn: CJA Applications 401 W Central Boulevard - Suite 1200 Orlando FL 32801-0120 send original only Application for Membership in Criminal Justice Act Revised: April 15, 2009 Middle District of Florida Page 7 of 7 American LegalNet, Inc. www.FormsWorkflow.com