APPLICATION FOR JUDICIAL VACANCY Nebraska Court System Court for which application is being submitted This application shall be available to the public and shall be preserved by the State Court Administrator for not less than 10 years. GENERAL INFORMATION 1. Full Name First Middle Last 2. Are you 30 years old or older? Yes No 3. Are you a citizen of the United States? Yes No 4. Home Address Street City State Zip Code Street City State Zip Code Home Phone 5. Business Address Business Phone 6. Length of residence in Nebraska 7. Number of years practicing law in Nebraska 8. Number of years practicing law in other states 9. years Residence addresses for the past 10 years , in states of 12/98 – Pg. 1 of 5, APP American LegalNet, Inc. www.FormsWorkflow.com EDUCATION 10. List each college and law school attended, including dates of attendance, degree(s) awarded, and reason for leaving each school if no degree was awarded. LEGAL CAREER 11. List all firms with which you have been associated in practice; governmental agencies, private business organizations, or colleges by which you have been employed; periods you have practiced as a sole practitioner; law clerkships; and other prior legal employment. Include dates of employment and positions held. List your most recent employment first. 12. List all courts, State Bar Associations, and administrative bodies having special admission requirements before which you are presently admitted to practice, including dates of admission. 13. Have you ever been reprimanded or otherwise disciplined by any disciplinary committee of the Nebraska State Bar Association, by the Supreme Court of the State of Nebraska, by the Nebraska Judicial Qualifications Commission, or by a similar committee or court in this or any other state? If so, please give particulars. 12/98 – Pg. 2 of 5, APP American LegalNet, Inc. www.FormsWorkflow.com PRIOR JUDICIAL EXPERIENCE 14. If you have had prior judicial or quasi-judicial experience, describe the approximate number and nature of cases you have handled and years of service on the bench. HONORS AND PUBLICATIONS 15. List any honors, prizes, awards, or other forms of recognition received of which you feel the commission should be aware. MISCELLANEOUS 16. Have you ever been convicted for violation of any laws? If so, please give details (this includes violations that have been set aside or expunged.) Do not include traffic violations unless they also included a potential jail sentence. 17. Have you ever had your driver's license revoked, suspended, or impounded or has your privilege to drive a motor vehicle ever been restricted for the violation of any law? ____ Yes ____ No. If so, when and in what state? 18. If you have additional information that you wish the commission to consider in the public portion of the application process, you may attach a resume or vita to this form. Please return original copy and attached Fair Credit Reporting Act Disclosure Statement and Waiver of Confidentiality plus 16 copies of each promptly to the Supreme Court Chair of the Judicial Nominating Commission to which you are making application. Send to: Nebraska Supreme Court P.O. Box 98910 Lincoln, Nebraska 68509 12/98 – Pg. 3 of 5, APP American LegalNet, Inc. www.FormsWorkflow.com Fair Credit Reporting Act Disclosure Statement The Federal Fair Credit Reporting Act, as amended by the Consumer Credit Reporting Reform Act of 1996, permits the procurement of consumer credit reports for employment purposes. The Act provides that a clear and conspicuous disclosure shall be made in writing to the applicant before the report is procured, that a consumer report may be obtained for employment purposes and the applicant shall authorize the procurement of the report in writing. In using the report for employment purposes, before taking any adverse action based in whole or in part on the report, the subscriber shall provide the applicant a copy of the report and a copy of “Summary of Consumer Rights”. The information from the report will not be used in violation of any applicable federal or state equal employment law or regulation. The Nebraska Supreme Court has contracted with the Lincoln Credit B ureau of Lincoln, Nebraska to procure a consumer credit report on each judicial vacancy applicant. A copy of the applicant=s report, instructions to the report, and “Summary of Consumer Rights” document will be mailed to the home address of the applicant as soon as possible after the filing deadline for the judicial vacancy. A copy of the applicant=s consumer credit report and instructions to the report will be included in the materials provided to each member and alternate member of the Judicial Nomination Commission. If the applicant=s name is submitted to the Governor for consideration, a copy of the consumer credit report will be forwarded to the Governor. Any corrective documentation of the consumer credit report will be provided to the commission members and if applicable, to the Governor. Authorization I hereby authorize the Nebraska Supreme Court to obtain a copy of my consumer credit report for employment purposes. Name (Please Print) Signature of Applicant Date Signed and sworn to this day of , . Notary Public 12/98 – Pg. 4 of 5, APP American LegalNet, Inc. www.FormsWorkflow.com Waiver of Confidentiality Application for Judicial Vacancy and Personal Data Sheet Nebraska Judicial Nominating Commission I hereby state that to the best of my knowledge the answers to all questions contained in my application and personal data sheet are true, and I understand that knowingly providing false information may subject me to removal from office. I understand that by submitting this application I am consenting to investigation and verification of any information listed in both the Application for Judicial Vacancy and the Personal Data Sheet. I authorize the Nebraska State Bar Association or any of its committees, the office of the Counsel for Discipline, the Judicial Qualifications Commission, educational institutions I have attended, any references furnished by me, employers, business and professional associates, law enforcement agencies, all governmental agencies and instrumentalities and all other public or private agencies or persons maintaining records pertaining to my citizenship, residency, age, credit, taxes, education, employment, civil litigation, criminal litigation, law enforcement investigation, admission to the practice of law, service in the U. S. Armed Forces, or disciplinary history to release to the Judicial Nominating Commission or its agent(s) any information, files, records, or reports requested by the commission in connection wit h any consideration of me as a possible nominee for appointment to judicial office. Submission of this application expresses my willingness to accept an appointment if tendered by the Governor, and my willingness to serve as judge in all matters falling under the jurisdiction of the Court for which I have submitted this application. If my name is submitted to the Governor for consideration, I authorize the release of the information contained in my Personal Data Sheet and the release of any other investigative materials to the Governor of the State of Nebraska. Name (Please Print) Signature of Applicant Date Signed and sworn to this day of , . Notary Public Appendix 2: Application Package 12/98 – Pg. 5 of 5, APP American LegalNet, Inc. www.FormsWorkflow.com