APPLICATION FOR AN ADDITIONAL THREE-YEAR TERM ON THE CJA PANEL FOR THE EASTERN DISTRICT OF NEW YORK (Please attach any other information that you deem relevant.) (Please type or print) NAME____________________________________OFFICE TELEPHONE__________________ FIRM NAME___________________________________________________________________ OFFICE ADDRESS_____________________________________________________________ FAX NO.________________________E-MAIL ADDRESS________________________________ RESIDENCE ADDRESS____________________________________________________________ YEAR APPOINTED TO CJA PANEL, EDNY________________________________________ 1) PLEASE LIST ANY CRIMINAL CASES YOU HAVE BEEN ASSIGNED FROM THE CJA PANEL DURING THE PAST THREE YEARS. ______________________________________________________________________________ _______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2) HAVE YOU BEEN UNABLE TO ACCEPT ANY PANEL ASSIGNMENT OR ANY “ON CALL” DUTY DAYS WITHIN THE LAST THREE YEARS? IF SO, PLEASE EXPLAIN COMPLETELY. YES_____ NO_____ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Page -1American LegalNet, Inc. www.USCourtForms.com 3) HOW MANY FEDERAL CRIMINAL CASES HAVE YOU HANDLED DURING THE LAST THREE YEARS (INCLUDING RETAINED CASES)?_______________________ OF THAT NUMBER, HOW MANY WERE: i) INVESTIGATIVE STAGE ONLY____________ ii) PLEAS OF GUILTY_______________________ iii) TRIALS TO VERDICT_____________________ a) b) iv) JURY_____________________________ NON-JURY________________________ OTHER DISPOSITION_____________________ (INDICTMENT DISMISSED, ETC.) 4) HOW MANY TIMES HAVE YOU BEEN RELIEVED OF A CJA PANEL ASSIGNMENT OR IN A RETAINED CRIMINAL CASE UPON APPLICATION, OR OTHERWISE, DURING THE LAST 5 YEARS?_____________________________________________ IF ANY INSTANCES, PLEASE EXPLAIN EACH ONE. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 5) HAS YOUR APPLICATION TO ANY ASSIGNED PANEL BEEN TURNED DOWN? ________________ IF SO, PLEASE GIVE PARTICULARS. _______________________________________________________________________________ _______________________________________________________________________________ ______________________________________________________________________________ Page -2American LegalNet, Inc. www.USCourtForms.com 6) HAVE YOU EVER BEEN REMOVED FROM ANY PANEL?_____________________ IF SO, PLEASE IDENTIFY THE PANEL, DATE OF REMOVAL, AND REASON FOR REMOVAL.______________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 7) HAVE YOU EVER BEEN THE SUBJECT OF A BAR DISCIPLINARY PROCEEDING, OR ARE ANY DISCIPLINARY MATTERS INVOLVING YOU PENDING?__________ IF SO, PLEASE GIVE PARTICULARS. ______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 8) HAVE YOU EVER BEEN THE SUBJECT OF A CONTEMPT PROCEEDING?_______ IF SO, GIVE PARTICULARS. ______________________________________________________________________________ _______________________________________________________________________________ ______________________________________________________________________________ 9) HAVE YOU EVER BEEN CONVICTED OF A CRIME (INCLUDING MISDEMEANORS AS WELL AS FELONIES); OR ARE THERE ANY CRIMINAL CHARGES PENDING AGAINST YOU?_________________________ IF SO, PLEASE GIVE PARTICULARS. ______________________________________________________________________________ _______________________________________________________________________________ ______________________________________________________________________________ Page -3American LegalNet, Inc. www.USCourtForms.com 10) I HEREBY AGREE TO ABIDE BY THE DECISION OF THE CRIMINAL JUSTICE ACT COMMITTEE ON ALL MATTERS, INCLUDING REMOVAL FROM THE PANEL. DATE__________________________ __________________________________________ APPLICANT’S SIGNATURE ___________________________________________ PRINTED NAME Page -4American LegalNet, Inc. www.USCourtForms.com