APPLICATION FORM UNITED STA TES MAGISTR ATE JUDGE UNITED STATES DISTRICT FOR THE DISTRICT OF NEW JERSEY Type or legibly print your an swers. If a question in not applicab le, indicate this by marking “N/A.” Return completed form to Cler k of Court. 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. __________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com 8. Military Service: Branch:_________________________Dates:_____________________________ _________________________ Rank o r Rate o f Disch arge _____________________________ Type o f Disch arge _____________________________ __________________________________ If still a reserve or natio nal guard me mber, give service, branch, u nit and pres ent rank______________________________________________________________ 9. Are you related by blood or marriage to any judge of this court? Yes____No____ If yes, give name(s) and relationship.____________________________________ __________________________________________________________________ Health 10. What is the present state of your health?_________________________________ 11. Do you have any disability, serious illness or condition that would prevent you from performing the essential functions o f the position. ______________________________________________________ __________________________________________________________________ 11. a) Have you in the last 10 years (i) been hospitalized due to injury or serious mental or physical illness or drug or alcohol addiction, or (ii) been prevented from working or otherwise incapacitated for a period in excess of ten days due to injury or illness, drug or alcohol addiction? If so, give the particulars, including the causes, the dates, the places of confinement, and the present status of the conditions which caused the confinement or incapacitation._____________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 2 American LegalNet, Inc. www.USCourtForms.com b) Do you have any visual or hearing impairment or other mental or physical impairment that would affect your ability to perform the duties of a magistrate judge: If so, please describe th e impairmen t and how your impa irment could be accom modated to allow you to perform the duties of a magistrate judge? __________________________________________________________________ __________________________________________________________________ Educat ion 12. Colleges and universities attended, dates, and degrees: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ 13. Continuing legal education courses completed within last 10 years:____________ __________________________________________________________________ __________________________________________________________________ Honors 14. Were you a member of law review? Yes________ No________. If yes, describe role:______________________________________________________________ __________________________________________________________________ 15. If you have published any legal books or articles, list them, giving citations and dates:_____________________________________________________________ __________________________________________________________________ 16. List any honors, prizes, or awards you have received:_______________________ __________________________________________________________________ __________________________________________________________________ 3 American LegalNet, Inc. www.USCourtForms.com Professional Admiss ions 17. List all courts (including state bar admissions) and administrative bodies having special admission requirements in which you are presently admitted to practice4, giving the dates of admission in each case: Court or Administrative Body Date of Admission ___________________________________________ __________________ ___________________________________________ __________________ ___________________________________________ __________________ Law Practice 18. State the n ames, a ddress and da tes of em ploym ent for a ll law firm s with w hich yo u 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 _________________________ ___________________ _______________ ___________ _________________________ ___________________ _______________ ___________ _________________________ ___________________ _______________ ___________ _________________________ ___________________ _______________ ___________ 19. Describe the general nature of your current practice including any legal specialities and character of your typical clients: also, if your practice is substantially different now than previously, give details of prior practice. ______________________________________ _______________________________________________________________________ _______________________________________________________________________ 20. a) Do you appear in Court? Yes________No________ 4 American LegalNet, Inc. www.USCourtForms.com b) Wha t percentage o f your app earances in the last five year s were in 1. Federa l courts 2. State or local courts of record __________% 3. Administrative bodies __________% 4. Other 21. __________% __________% During the past five years, what percentage of your practice has been trial practice? __________% 22. How frequently have you appeared in court? __________times per month. 23. How frequently have you appeared at administrative hearings? __________times per month. 24. What percentage of your practice involving litigation has been: Civil __________% Criminal __________% Other: ________________ __________% ________________ __________% ________________ __________% 5 American LegalNet, Inc. www.USCourtForms.com 25. 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. _______________________________________________________________________ _______________________________________________________________________ 26. Summarize your courtroom experience for the past five years:_____________________ _______________________________________________________________________ _______________________________________________________________________ 27. State the names and addresses of adversary counsel against whom you have litigated your primary cases over the past five years:____________________________________ _______________________________________________________________________ _______________________________________________________________________ Public Office 28. Have y ou ever r un for, o r held p ublic of fice? Y es___ _____ No__ _____ _. If yes, give details. _________________________________________________________________ _______________________________________________________________________ Prior Judicial Experience 29. a) Have you ever held judicial office or been a candidate for judicial office? If so, state the courts involved and the dates of service or dates of candidacy:__________________ _______________________________________________________________________ _______________________________________________________________________ 6 American LegalNet, Inc. www.USCourtForms.com b) If you h ave held judicial office, s tate the n ames an d addre sses of c ounse l who h ave appeared before you who would be knowledgeable of your work, temperament and abilities:________________________________________________________________ _______________________________________________________________________ c) Prior quasi-judicial service: Name of agency:________________________________________________________ Position held:__________________________________________________________ Hearings on what types of issues:__________________________________________ Number of cases adjudicated:_____________________________________________ Dates of service:________________________________________________________ Business Involve ment 30. a) If you are now an officer, director, or otherwise engaged in the management of any business enterprise, state the nam e of such enterprise, the natu re 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, h ave you ever engaged in any oc cupation, business, or profession other than the practice of law? Yes________No________. If yes, give the details, including dates:_______________________________________________ _______________________________________________________________________ 7 American LegalNet, Inc. www.USCourtForms.com c) During the past five years, have you received any fees or comp ensation 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 co mpensation, the nature o f the business enterprise, institution, organization or association involved, and the dates such compensation was paid. _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 31. a) Have you ever been arrested, charged, or convicted for violation o f any federal law, state law, county or municipal law, regulation, or ordinance? Yes_____ ___No__ ______. If yes, give details. (Do not includ e traffic violations for which a fine of $20 0 or less was imposed unless it also included a jail sentence .) _______________________________________________________________________ _______________________________________________________________________ b) Have you, to you r knowledge, ever been un der federal, state, or local investigation for possible violation of a criminal statue? Yes__________No__________. If yes, give particulars. ___________________________________________________________ 32. a) Have you ever been sued by a client? Yes__________No__________. If yes, give particulars. ____________________________________________________________ _______________________________________________________________________ b) Have yo u or your p rofessiona l liability insuran ce carrier ever settled a claim a gainst you for professional malpractice? Yes________No________. If yes, give particulars, including the amounts involved. _______________________________________________________________________ _______________________________________________________________________ 33. Have you ever been ch arged in any civil or criminal pr oceedings w ith conduc t alleged to involve moral turpitude, dishonesty, or unethical conduct? Yes________No________. If yes, give particulars. ____________________________________________________ _______________________________________________________________________ 34. 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.______________________________ _______________________________________________________________________ _______________________________________________________________________ 8 American LegalNet, Inc. www.USCourtForms.com 35. Have you filed appropriate tax returns as required by federal, state, local, and other government authorities? Yes________No________. If no, explain._________________ _______________________________________________________________________ _______________________________________________________________________ 36. 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 37. a) List all bar associations and legal profession al 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.__________________________________________________________ _______________________________________________________________________ 9 American LegalNet, Inc. www.USCourtForms.com Supplemen tal Informat ion 38. State any achievements or actions you have accomplished, demonstrating your commitment to equal justice under the law._____________________________________ _______________________________________________________________________ _______________________________________________________________________ 39. State any add itional educ ation or othe r experien ces you b elieve wou ld assist you in holding judicial office._____________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 40. State any other pertinent information reflecting positively or adversely on you which you believe shou ld be disclos ed to the distric t court and th e selection p anel in con nection w ith your possible nomination as United States magistrate judge.___________________ _______________________________________________________________________ _______________________________________________________________________ 41. a) List three individuals as reference who are familiar with your abilities. Name Address Telephone ______________________________ _________________________ _____________ ______________________________ _________________________ _____________ ______________________________ _________________________ _____________ 10 American LegalNet, Inc. www.USCourtForms.com b) List three individuals as references w ho are familiar with your p ersonal character. Name Address Telephone ______________________________ ________________________ _____________ ______________________________ ________________________ _____________ ______________________________ ________________________ _____________ Confidentiality Sta tement This form w ill be kept confid ential and w ill be examin ed only by members o f 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 individu als will be co ntacted w ithout you r prior appro val. I declare und er penalty o f perjury tha t the foregoing is tru e and corre ct. Executed on __________________________ _____________________________________________ Date Signature of C andidate PLEASE SUBMIT AN ORIGINAL AND 14 COPIES ______________________________________________________________________________ THE DISTRICT COURT IS AN EQUAL OPPORTUNITY EMPLOYER 11 American LegalNet, Inc. www.USCourtForms.com