QUESTIONNAIRE AND APPLICATION FOR MEMBERSHIP IN THE CRIMINAL JUSTICE ACT PANEL FOR THE UNITED STATES DISTRICT COURT FOR THE SOUTHERN 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 Southern District of Florida: THE APPLICANT IS HEREWITH APPLYING FOR APPOINTMENT AS A CJA PANEL ATTORNEY. 1. Name:____________________________________________ Office Address: ______________________________________________________ ______________________________________________________ Office Phone: ______________________________________________________ Home Address: ______________________________________________________ ______________________________________________________ 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 Southern 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: ________________________________________ American LegalNet, Inc. www.FormsWorkflow.com Application for Membership in Criminal Justice Act Southern District of Florida Pag e 2 of 6 Others: Jurisdiction or Court Location Date _________________________ _______________ ___________________ _________________________ _______________ ___________________ _________________________ _______________ ___________________ 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 Appellate ________ Civil Trial 3. _______ _______ Other ________ Disciplinary Actions: Have you ever been disciplined or have any complaints been filed against you or are you the subject of any pending disciplinary action by the Bar of any jurisdiction or by any Court? __________________ 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 __________________________________ Served as state defender __________________________________ Served as federal prosecutor __________________________________ 2 American LegalNet, Inc. www.FormsWorkflow.com Application for Membership in Criminal Justice Act Southern District of Florida Pag e 3 of 6 Served as state prosecutor __________________________________ Served in private practice __________________________________ Served as a Law Clerk __________________________________ Other: (please describe) ______________________________________________ ________________________________________________________________________ 5. Have you at any time been a member of the CJA Panel for this Court? ______ For any other Court? (Please give court title.) ________________ If so, please give dates: ___________________________________________________________________________ 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? United States District Court: (pre-guidelines) (post-guidelines) State Court: __________________________ __________________________ __________________________ Approximately how many civil cases have you tried to verdict? All courts: ____________________. 3 American LegalNet, Inc. www.FormsWorkflow.com Application for Membership in Criminal Justice Act Southern District of Florida Pag e 4 of 6 Please list all trials that you have had in the last three years (attach additional sheet if necessary): Judge Court* Case Name and Number Date of Trial ____________________ ____________ _______________________ _______________ ____________________ ____________ _______________________ _______________ ____________________ ____________ _______________________ _______________ ____________________ ____________ _______________________ _______________ ____________________ ____________ _______________________ _______________ ____________________ ____________ _______________________ _______________ * If a state co urt trial, please identify the cou nty. If a federal trial outside the Sou thern D istrict of Florid a, please ide ntify the distric t. 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). __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 4 American LegalNet, Inc. www.FormsWorkflow.com Application for Membership in Criminal Justice Act Southern District of Florida Pag e 5 of 6 9. Describe briefly the nature of your present practice: __________________________________________________________________________ __________________________________________________________________________ 10. Are you fluent in any of the following foreign languages? Spanish ________ Other Creole ________ ________ If other, please indicate which language(s) _____________________________________________________________________ 11. It is likely that most appointments will be made to CJA lawyers who will rotate "duty" days in magistrates’ court. Would you be available to serve in the courthouse as Duty Attorney on an assigned Duty Day? Yes 12. ______ No _______ In which federal courts are you available to receive appointment in (check boxes): Dade [ ] Monroe [ ] Broward [ ] Ft. Pierce [ ] Palm Beach [ ] 13. In which of the following categories of cases will you accept appointment (check boxes): I. II. III. 0 to 5 days [ ] 6 to 10 days [ ] 11 to 20 days [ ] IV. V. 21 to 60 days 61 days and over [ ] [ ] 5 American LegalNet, Inc. www.FormsWorkflow.com Application for Membership in Criminal Justice Act Southern District of Florida Pag e 6 of 6 14. Are you willing to handle "cold record" appeals (appeals from trials in which you were not trial counsel): Yes 15. ______ 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: ___________________________________ MAIL TO: Kathleen M. Williams, Federal Public Defender Southern District of Florida 150 West Flagler Street Suite 1500 Miami, Florida 33130-1555 (Attn: CJA Desk) ALSO: Send a copy to: Steven M. Larimore, Clerk/Administrator United States District Court Southern District of Florida United States District Courthouse 400 North Miami Avenue, Room 8N09 Miami, Florida 33128-7716 (Attn: CJA Desk) 6 American LegalNet, Inc. www.FormsWorkflow.com