The Commonwealth of Massachusetts THE ADMINISTRATIVE OFFICE OF THE SUPERIOR COURT APPLICATION FOR FEE GENERATING APPOINTMENTS IN THE SUPERIOR COURT Name Address City Phone Number State Fax Number BBO# Zip Code E-Mail I certify: Date of Admission that I remain in good standing to practice before the courts of the Commonwealth of Massachusetts; that I have not been convicted of any felony; that I have currently in effect professional liability insurance with coverage of $100,000 or more; and that I have at least ten years experience as a practicing attorney within the Commonwealth. I request that I be appointed as a: Master Receiver Arbitrator Guardian Ad Litem I request and will accept appointments from the Superior Court in the following counties (not more than four): I agree that if I am appointed as a master, receiver, arbitrator or guardian ad litem, and the court or attorney/party in the case requests a certificate of my professional liability insurance, that I will provide it within seven days of the request. I have attached a letter of interest and a copy of my resume to this application. I certify under the penalties of perjury that all of the above information is true. Current Date 9/7/13 Signature PLEASE SUBMIT APPLICATIONS TO: Susan K. Marcucci, Regional Coordinator, Superior Court Administrative Office, Three Pemberton Square, Boston, MA 02108 or via email at susan.marcucci@jud.state.ma.us. American LegalNet, Inc. www.FormsWorkFlow.com