CJA App. 11/2011 QUESTIONNAIRE AND APPLICATION FOR MEMBERSHIP ON THE PANEL OF PRIVATE ATTORNEYS UNDER THE CRIMINAL JUSTICE ACT PLAN FOR THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF NEW JERSEY This questionnaire and application is to be completed by attorneys who wish to apply to the Court to represent eligible criminal defendants under the provisions of the Criminal Justice Act Plan adopted by the United States District Court for the District of New Jersey. Completed applications can be submitted by e-mail to njcja@njd.uscourts.gov. Any questions, please contact Michelle Stortini at 609-989-0500. 1. FULL NAME: 2. OFFICE ADDRESS (Including name of law firm) 3. HOME ADDRESS Office Telephone: Home Telephone: Fax Number: E-mail: 4. EDUCATION: Name and Address of Law School Date of Graduation and Degree Received: 5. BAR ADMISSIONS -- Admitted to Practice In: Date Admitted: Supreme Court of New Jersey Date Admitted: United States District Court, District of New Jersey United States Court of Appeals for the Third Circuit United States Supreme Court Date Admitted: Date Admitted: Bar Admission in other Jurisdictions Please list each court with admission date: 6. DISCIPLINARY ACTIONS (a) Have you ever been the subject of a disciplinary action by any court? Yes No (b) Are you the subject of any pending disciplinary proceeding? Yes No If yes, please explain in detail the circumstances of any disciplinary action(s) in which you were charged, and the results. With respect to any pending disciplinary charge(s), please describe the procedural posture of the pending proceeding(s) and the anticipated date of its disposition. Attach a separate sheet if necessary. American LegalNet, Inc. www.FormsWorkFlow.com 7. PRACTICE BACKGROUND (a) Have you ever been employed as a full-time prosecutor, public defender, or law clerk to a judge or justice? Yes No If yes, please describe the position, the name of your employer, and the dates of employment. Attached a separate sheet if necessary. (b) Have you ever been appointed by this Court to represent an eligible criminal defendant pursuant to the Criminal Justice Act? No Yes Any Other Courts? No Yes The United States Court of Appeals for the Third Circuit? Yes No If yes, please identify the Court and list the dates of your appointment(s). Attach a separate sheet if necessary. (c) Please describe any continuing legal education experience you may have had, either as a lecturer or participant in criminal or trial advocacy programs, within the past five years. Attach a separate sheet if necessary. 8. TRIAL EXPERIENCE (a) Approximately how many felony cases have you tried to verdict in: United States District Court for the District of New Jersey Superior Court of New Jersey Other Courts Please describe the felony cases you have tried to verdict. List no more than ten cases. Attach a separate sheet if necessary Page 2 of 4 CJA App. 11/2011 American LegalNet, Inc. www.FormsWorkFlow.com (b) Approximately how many pleas and sentencings have you handled in: United States District Court for the District of New Jersey - pre-guidelines United States District Court for the District of New Jersey - post-guidelines Superior Court of New Jersey Other Courts Please describe the Federal Sentencing Guidelines cases you have handled. List no more than ten cases. Attach a separate sheet if necessary. (c) Approximately how many civil cases have you tried to verdict? Please describe each of the civil cases you have tried to verdict. List no more than ten cases. Attach a separate sheet if necessary. (d) Have you had trial experience in a state or federal death penalty case? Yes No If yes, please describe each of the death penalty cases in which you have had trial experience. In addition, please describe any appellate experience you may have had in state or federal death penalty cases, including post conviction relief or habeas corpus proceedings. Attach a separate sheet if necessary. Page 3 of 4 CJA App. 11/2011 American LegalNet, Inc. www.FormsWorkFlow.com 9. SPECIAL QUALIFICATIONS Please indicate whether you have any special qualifications, such as Certification as a Criminal Trial Attorney, fluency in a foreign language, or expertise in a specialized area of law, e.g., immigration, which you believe the Plan Selection and Management Committee should be aware of in reviewing your application. Attach a separate sheet if necessary. 10. DURATION OF APPOINTMENT I understand that if I am appointed to represent a criminal defendant in any case before the United States District Court for the District of New Jersey pursuant to its Criminal Justice Act Plan, the appointment will continue through any appeal that may be taken to the United States Court of Appeals for the Third Circuit and to the United States Supreme Court, and any Rule 35 Motion for Reduction of Sentence which may be appropriate following the conclusion of the appeals, as well as any related proceedings that may result from the appellate process, unless relieved from the appointment by Order of Court. Yes No 11. EXTENT OF REPRESENTATION (a) I am willing to represent litigants under the Criminal Justice Act on appeal in cases in which I have not been appointed as counsel before the District Court. Yes No (b) I am willing to represent petitioners (other than those sentenced to death) who sue under 28 U.S.C. Sections 2254 or 2255 for habeas corpus relief. Yes No (c) Do you have a preference as to which Vicinage you wish to serve in as a member of the CJA Panel? Yes No If yes, please indicate your Vicinage preference: Camden Newark Trenton 12. APPLICANT DECLARATION I have reviewed the current Criminal Justice Act Plan adopted by the United States District Court for the District of New Jersey and agree to be bound by its terms and conditions. I declare under penalty of perjury that the forgoing answers and statements are true and correct. Executed On: Signature of Applicant (for E-Mail submission please use s/Name) (Date) FOR SELECTION COMMITTEE USE ONLY: Applicant Accepted Vicinage Assignment: Applicant Rejected Camden Newark Trenton Comments: Page 4 of 4 CJA App. 11/2011 American LegalNet, Inc. www.FormsWorkFlow.com