Approved, SCAO CASE EVALUATOR APPLICATION To serve as a case evaluator, you must meet the following qualifications. � � � � � You must have been a practicing lawyer for at least 5 years. You must be a member in good standing of the State Bar of Michigan. You must reside, maintain an office, or have an active practice in the jurisdiction for which the list of case evaluators will be compiled. You must demonstrate that a substantial portion of your practice for the last 5 years has been devoted to civil litigation matters including investigation, discovery, motion practice, case evaluation, settlement, trial preparation, and/or trial. If the court maintains sublists for specific types of cases (such as professional malpractice, commercial, labor and employment), you must have had an active practice in those areas. For further information, refer to MCR 2.404. Please type or print clearly. 1. Full name (first, middle initial, last) 3. Residence address 5. Business address (if different from residence address) 7. Current employer's name 9. Previous employer's name 11. Fax no. 12. E-mail address 14. Years in practice 2. Bar no. P 4. Home telephone no. ( ( ) ) 6. Business telephone no. 8. Number of years with employer 10. Number of years with employer ( ) 13. Date admitted to state bar Part A: General Information 15. This is a new application. renewal. Yes No 16. Are you currently a member in good standing of the State Bar of Michigan? 17. Have you ever been disciplined by the Michigan Attorney Discipline Board or any other state or federal agency or court? If yes, explain. Complete on separate pages if needed. Yes No 18. Provide information that demonstrates experience in civil litigation including investigation, discovery, motion practice, case evaluation, settlement, trial preparation, and/or trial for the last 5 years. For any trial experience, include the name of the case, the year of trial, the case number, the number of trial days, the name of the court, the name of the judge, and whether you represented the plaintiff or the defendant. Complete on separate pages if needed. MC 34 (3/13) CASE EVALUATOR APPLICATION, Page 1 of 3 MCR 2.404 American LegalNet, Inc. www.FormsWorkFlow.com Case Evaluator Application, continued from page 1 19. Indicate the percent of your law practice for the past 5 years devoted to civil litigation matters, including investigation, discovery, motion practice, case evaluation, settlement, trial preparation, and/or trial. _____ % plaintiff _____ %defense Indicate the percent of your current trial practice in the following areas: Personal injury/Auto negligence Professional malpractice Product liability Commercial Labor and Employment Condemnation Domestic relations Other _______________________ specify _____ % plaintiff _____ % plaintiff _____ % plaintiff _____ % plaintiff _____ % plaintiff _____ % plaintiff _____ % plaintiff _____ % plaintiff _____ % plaintiff _____ % defense _____ % defense _____ % defense _____ % defense _____ % defense _____ % defense _____ % defense _____ % defense _____ % defense Other _______________________ specify Part B: For Specialized Lists Complete Part B if the court maintains sublists for specific types of cases and you have had an active practice in those areas for at least the last 3 years. 20. Indicate which you primarily represent: Indicate the sublist(s) you are applying for: Plaintiff Defendant Neutral (not representing a majority of either) 21. List the areas of law in which you practice and how long you have practiced in each area. / Area of law Area of law Years practiced Area of law Years practiced Years practiced / Years practiced Area of law Part C: Additional Information 22. Provide any additional information about you that would be helpful in describing your qualifications to serve as a case evaluator, for example, teaching law school courses. Complete on separate pages if needed. I certify that I meet the requirements for service under the court's selection plan and that I will not discriminate against parties, attorneys, or other case evaluators on the basis of race, ethnic origin, gender, or other protected personal characteristics. Date MC 34 (3/13) Signature CASE EVALUATOR APPLICATION, Page 2 of 3 MCR 2.404 American LegalNet, Inc. www.FormsWorkFlow.com Case Evaluator Application - Gender and Race Information to be maintained separately from pages 1 and 2 of application Part D: Gender and Race Information Providing the following information is optional. It is requested in accordance with MCR 2.404(B)(1) and will be maintained separately from your application. Full name (first, middle initial, last) (print or type) Bar no. P Check the boxes that apply to you. Gender: Female Race/Ethnicity: American Indian or Alaskan Native Asian or Pacific Islander Black/African American (non-Hispanic) Hispanic White/Caucasian (non-Hispanic) Other Male MC 34 (3/13) CASE EVALUATOR APPLICATION, Page 3 of 3 MCR 2.404 American LegalNet, Inc. www.FormsWorkFlow.com