BENCH-BAR COMMITTEE APPLICATION FOR MEMBERSHIP Name: Firm Name: Address: City, State, Zip Code: Phone: E-Mail Address: College and Undergraduate Degree: Law School and Date of Graduation: Date(s) of Admission to Practice: U.S. District Court Supreme Court of Kansas Others(s) (specify) Nature/Area of Practice (Check): State Federal Civil Criminal Plaintiff Defendant In-House Counsel Areas of Specialization: Explain why you are interested in serving on this committee: Past service on any federal court committee(s): Bar membership and other extracurricular activities: Please answer the following questions regarding disciplinary matters and registration status: I am in good standing in all bars of which I am a member: Yes No (Please explain on Page 2) No disciplinary or grievance proceedings have been previously filed against me nor are any pending against me in any jurisdiction True False (Please explain on Page 2) I have not been charged in any court of the United States or of any state, territory or possession of the United States with the commission of a felony or unprofessional conduct. True False (Please explain on Page 2) I am registered as an active attorney with this court and have paid the dues for the current registration period. Yes No (Please explain on Page 2) Signature Date ( Revised 3/29/ 17 ) Please complete the following application and attach a current copy of your resume. If additional space is needed, please use Page 2 of this form . American LegalNet, Inc. www.FormsWorkFlow.com BENCH-BAR COMMITTEE APPLICATION FOR MEMBERSHIP Page 2 Please use the space below if responses on Page 1 require explanation. American LegalNet, Inc. www.FormsWorkFlow.com