APPLICATION FORM UNITED STATES MAGISTRATE JUDGE Please submit the original and nine copies of the completed application form, marked confidential, to: United States District Court, District of Nevada Clerk of Court 333 Las Vegas Boulevard South Las Vegas, Nevada 89101 All applications must be received by the Clerk of Court no later than close of business on January 21, 2005. General 1. Full name: 2. All other names by which you have been known: 3. Office address: City State Zip Telephone 4. Residential address: City State Zip Telephone 5. Place of birth: Date of birth: 6. Length of residence in state: 7. If you are a naturalized citizen, state the date and place of naturalization. 8. Military Service: Branch Dates Rank or Rate at Discharge Type of Discharge If still a reserve or national guard member, give service branch, unit and present rank. Are you related by blood or marriage to any judges of this court?: Yes No . If yes, give name(s) and relationship. 9. Health 10. What is the present state of your health? 11. Do you have any visual or hearing impairment or other mental or physical impairment that could interfere with your ability to perform the duties assigned to a magistrate judge? Yes No If yes, specify. 12. Have you had any non-elective hospital confinement, mental illness, serious physical illness, or drug or American LegalNet, Inc. www.FormsWorkflow.com alcohol addiction during the past ten years? Yes No . If yes, explain and identify your attending physician, the names of any hospital or other institution to which you were admitted and the date(s) of your hospitalization. 13. Are you presently receiving treatment for a physical or mental illness or condition, or drug or alcohol addiction? If yes, give details. Education 14. Colleges and universities attended, dates and degrees: 15. Continuing legal education courses completed within last ten (10) years: Honors 16. Were you a member of law review? Yes 17. If you have published any legal books or articles, list them, giving citations and dates: 18. List any honors, prizes, or awards you have received: No . If yes, describe the role: Professional Admissions 19. List all courts (including state bar admissions) and administrative bodies having special admission requirements in which you are presently admitted to practice, giving the dates of admission in each case: Court or Administrative Body Date of Admission Law Practice 20. State the names, addresses, and dates of employment for all law firms with which you have been associated in practice, all government agencies, and all private business organizations in which you have been employed. Also provide all dates during which you have practiced as a sole practitioner. Organization Address Position Dates 21. Describe the general nature of your current practice including any legal specialties and character of your typical clients; also, if your practice is substantially different now than previously, give details of prior practice. 22. A) Do you appear regularly in court? Yes No . B) What percentage of your appearances in the last five years were in 1. 2. 3. 4. Federal courts State or local courts of record Administrative bodies Other % % % % 23. During the past five years, what percentage of your practice has been trial practice? 24. How frequently have you appeared in court? 25. How frequently have you appeared at administrative hearings? times per month. 26. What percentage of your practice involving litigation has been Civil Criminal % times per month. % % American LegalNet, Inc. www.FormsWorkflow.com Other: % 27. State the number of cases you have tried to conclusion in courts of record during the past five years, indicating whether you were sole, associate, or chief counsel. Give citations of any reported cases. 28. Summarize your courtroom experience for the past five years. 29. State the names and addresses of counsel against whom you have litigated your primary cases over the past five years. Public Office 30. Have you ever run for, or held, public office? Yes No . If yes, give details. Prior Judicial Experience 31. A) Have you ever held a judicial office or been a candidate for a judicial office? If so, sate the courts involved and the dates of service, or dates of candidacy: B) Prior quasi-judicial service: Name of agency Position held Hearings on what types of issues Number of cases adjudicated Dates of service Business Involvement 32. A) If you are now an officer, director, or otherwise engaged in the management of any business enterprise, state the name of such enterprise, the nature of the business, the nature of your duties, and whether you intend to resign such position immediately upon your appointment to judicial office. B) Since being admitted to the bar, have you ever engaged in any occupation, business, or profession other than the practice of law? Yes No . If yes, give the details, including dates. C) During the past five years have you received any fees or compensation of any kind, other than for legal services rendered, from any business enterprise, institution, organization, or association of any kind? Yes No . If yes, identify the source of such compensation, the nature of the business enterprise, institution, organization or association involved, and the dates such compensation was paid. 33. A) Have you ever been arrested, charged, or convicted for violation of any federal law, state law, county or municipal law, regulation, or ordinance? Yes No . If yes, give details. (Do not include traffic violations for which a fine of $200 or less was imposed unless it also included a jail sentence.) B) Have you, to your knowledge, ever been under federal, state or local investigation for possible violation of a criminal statute? Yes No . If yes, give particulars. 34. A) Have you ever been sued by a client? Yes No . If yes, give particulars. B) Have you or your professional liability insurance carrier ever settled a claim against you for professional American LegalNet, Inc. www.FormsWorkflow.com malpractice? Yes No . If yes, give particulars, including the amounts involved. 35. Have you ever been charged in any civil or criminal proceedings with conduct alleged to involved moral turpitude, dishonesty, or unethical conduct? Yes No . If yes, give particulars. 36. Have you ever been disciplined or cited for a breach of ethics or unprofessional conduct by any court, administrative agency, bar association, or other professional group? Yes No . If yes, give particulars. 37. Have you filed appropriate tax returns as required by federal, state, local, and other government authorities? Yes No . If no, explain. 38. Have any liens or claims ever been instituted against you by the federal, state or local authorities? Yes No . If yes, explain. Professional and Other Activities 39. A) List all bar associations and legal professional societies of which you are a member and give the titles and dates of any office you have held in such groups, and committees to which you belonged. B) List all organizations and clubs, other than bar associations and professional societies identified in response to Question 39. A), of which you have been a member during the past ten years, including the titles and dates of any offices you have held in each such organization. Supplemental Information 40. State any achievements or actions you have accomplished, demonstrating your commitment to equal justice under the law. 41. State any additional education or other experiences you believe would assist you in holding a judicial office. 42. State any other pertinent information reflecting positively or adversely on you which you believe should be disclosed to the district court and the selection panel in connection with your possible nomination as United States Magistrate Judge. 43. List five individuals as references who are familiar with your abilities and personal character: Name Address Telephone CONFIDENTIALITY STATEMENT This form will be kept confidential and will be examined only by members of the Merit Selection Panel and the judges of the district court. The individuals whom you have listed as references above may be contacted by the panel, but no other employers, colleagues, or other individuals will be contacted without your prior approval. I declare under penalty of perjury that the foregoing is true and correct. Executed on Date Signature of Candidate THE DISTRICT COURT IS AN EQUAL OPPORTUNITY EMPLOYER American LegalNet, Inc. www.FormsWorkflow.com WAIVER OF CONFIDENTIALITY (To be completed after initial screening of applicants) The Merit Selection Panel has completed its initial screening of applicants for the position of United States Magistrate Judge. We are now in need of additional information on your background and qualifications to determine whether to recommend you to the district court for appointment as a magistrate judge. Accordingly, we request your approval to consult with your current or past employers or colleagues, and other individuals who have material knowledge of your qualifications (including your physician) in order to verify and supplement the information contained in your application form. A Awaiver of confidentiality@ is printed immediately below for this purpose. Waiver I hereby authorize the custodian of any records or information to permit the examination or receipt of such information, whether written or oral, by the Merit Selection Panel. I also authorize the Merit Selection Panel to consult with my former employers, my current employer, my professional colleagues, and other individuals who have material knowledge of my qualifications (including my physician) with regard to matters pertinent to my qualifications for the position of a United State Magistrate Judge. Date Signature THE UNITED STATES DISTRICT COURT IS AN EQUAL OPPORTUNITY EMPLOYER American LegalNet, Inc. www.FormsWorkflow.com