CRIMINAL JUSTICE ACT APPLICATION FOR PANEL MEMBERSHIP This application form is also available via e-mail in WordPerfect format. Contact Traci Truitt at traci_truitt@fd.org to have the form e-mailed to you. Please indicate the panel you want to join: Southern District of Iowa Davenport Des Moines Northern District of Iowa Cedar Rapids Sioux City Name: _______________________________________________________________ Name of Firm:__________________________________________________________ Address: ______________________________________________________________ _____________________________________________________________________ Phone Number: ___________________________ Fax Number: __________________ E-Mail Address _____________________________ Firm's Employer I.D. #: ___________________________________________________ Soc. Sec.#___________________________ Bar No. __________________________ Law School:________________________________ Date/Degree: ________________ Jurisdictions in which currently admitted or licensed to practice law: State: Date of Admission: ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ U.S. District Court: Date of Admission: ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ U.S. Appellate Court: Date of Admission: ______________________________ ______________________________ ______________________________ ______________________________ Date of Admission to U.S. Supreme Court: ____________________________ American LegalNet, Inc. www.FormsWorkflow.com Legal References (lawyers or judges familiar with your legal skills): Name Phone Address _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Briefly describe the nature and length of your present practice: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Briefly describe the nature and length of any prior practice(s): _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Address of prior practice(s): _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Lawyers you frequently worked with in prior practice: Name Phone Address _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Prior criminal and civil experiences (trial and otherwise): TOTAL FEDERAL COURT STATE COURT Trials (Criminal) - Jury Trials (Criminal) - Non-Jury Trials (Civil) - Jury 2 American LegalNet, Inc. www.FormsWorkflow.com Trials (Civil) - Non-Jury Guilty Pleas Federal Guidelines Sentencings Do you own or have ready access to the following books or their equivalents? current United States Sentencing Guidelines Manual yes no current Federal Criminal Code and Rules yes no current 8th Circuit Model Uniform Criminal Jury Instructions yes no Federal judges and magistrate judges before whom you have tried a case: Judge Approximate Dates Case Name & Number _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Federal appellate experience: Circuit Oral Argument Held? Case Name & Number _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ Describe any specific experience or training you have in criminal law (other than already noted above): _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 3 American LegalNet, Inc. www.FormsWorkflow.com Has a final adjudication or other finding ever been made against you by any bar association, ethics committee, court or other judicial or quasi-judicial body concerning your ethics or any other disciplinary matter? YES NO If yes, please explain: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ I certify that the above information is true and correct. _______________________ Date _____________________________________ Signature This application should be sent to: Federal Public Defender’s Office 400 Locust Street, Suite 340 Des Moines, Iowa 50309 The CJA Panel Selection Committee meets regularly (at least once a year) to review applications for membership to the panel. After the committee has met to consider your application, you will be notified whether you have been admitted to serve on the panel. Thank you for your interest in serving. 4 American LegalNet, Inc. www.FormsWorkflow.com