APPLICATION FOR COUNTY PANEL OF ATTORNEYS FOR CHILDREN County Name of Applicant Firm Name Address City State Telephone Zip Code Fax E-mail Address NY Bar Admission Date Attorney Registration # Department 1. I am currently registered and in good standing with the Office of Court Administration as required by Section 468-a of the Judiciary Law (having paid all biennial fees as required). Yes No 2. I have an office and/or residence in panel county. Yes No 3. I have attended "Fundamentals of Law Guardian Advocacy" or "Introduction to Effective Representation of Children”. Yes No Date 4. Have you ever a. Been charged with or convicted of any crime? Yes No Yes No Yes No If yes, please state particulars and indicate the status thereof. b. Been sanctioned or held in contempt by any court? If yes, please state particulars. c. Had an order of protection issued against you? If yes, please state particulars. Rev. April 11, 2012 American LegalNet, Inc. www.FormsWorkFlow.com d. Been notified that you are the subject as a parent or person responsible for the care of a child of any indicated report to the Statewide Central Register of Child Abuse and Maltreatment? Yes No If yes, please state particulars and indicate the status thereof. e. Been suspended, removed or asked to resign from any assigned counsel plan or attorney for the child panel? Yes No If yes, please state particulars. f. Been notified by an attorney grievance committee that you are the subject of any complaint or disciplinary proceeding or that you are the subject of any professional discipline? Yes No If yes, please state particulars. 5. I have participated as counsel of record or as co-counsel with a mentor in: (1) A juvenile delinquency or person in need of supervision proceeding entitled in (2) A child abuse, child neglect, or termination of parental rights proceeding entitled in (3) County Family Court; County Family Court; A custody or visitation proceeding entitled in County Family Court; and have participated in or observed two hearings in Family Court at which testimony was taken entitled in County Family Court; and in County Family Court. Rev. April 11, 2012 American LegalNet, Inc. www.FormsWorkFlow.com 6. I was previously a member of the panel of attorneys for children in County from until 7. I have the following additional training and experience related to service as an attorney for the child: 8. I authorize the Committee on Professional Standards of the Third Judicial Department, or any other judicial department or grievance committee, to share with the Office of Attorneys for Children for the Third Judicial Department, any information relative to me as an attorney. 9. I certify that the foregoing information is true and correct Name (please print) Signature Date: Sworn to before me this day of 20 NOTARY PUBLIC Rev. April 11, 2012 American LegalNet, Inc. www.FormsWorkFlow.com Action by Family Court Judge I have determined that the applicant has met both the training and experience requirements for designation as an attorney for the child pursuant to § 835.2 (a) (1) (ii) and (iii) of the rules of the Appellate Division, Third Department, and hereby approve the application and recommend that the applicant be added to the panel of attorneys for children for this county. I have determined that the applicant has met the experience requirement for designation as an attorney for the child pursuant to § 835.2 (a) (1) (iii) of the rules of the Appellate Division, Third Department, and hereby approve the application and recommend that the applicant be added to the panel of attorneys for children for this county, subject to the requirement that the applicant attend the Introduction to Effective Representation of Children seminar within the first year of panel membership. I hereby defer action on the application, refer the applicant to as mentor, and direct that a copy of this application be forwarded to the Appellate Division’s Office of Attorneys for Children. I hereby deny the application for the following reasons: Dated: Signature: ************************************************************************************************************************ Approval of Deferred Application: Having previously deferred action on the application, I have now determined that the applicant has met the training and experience requirements for designation as a panel member pursuant to § 835.2 (a) (1) of the rules of the Appellate Division, Third Department, and hereby approve the application and recommend that the applicant be added to the panel of attorneys for children for this county. Dated: Signature: Rev. April 11, 2012 American LegalNet, Inc. www.FormsWorkFlow.com