NOTE: PLEASE ATTACH A DETAILED RÉSUMÉ TO YOUR APPLICATION FORM, AND ANY OTHER INFORMATION THAT YOU DEEM RELEVANT. APPLICATION FOR APPOINTMENT TO THE PANEL OF ATTORNEYS UNDER THE CRIMINAL JUSTICE ACT OF 1964 PURSUANT TO THE PLAN OF THE JUDGES OF THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF NEW YORK (Please print or type) NAME__________________________________TELEPHONE NO. ( ) FIRM NAME___________________________________________________________________ OFFICE ADDRESS______________________________________________________________ RESIDENCE ADDRESS_________________________________________________________ FAX NO.__________________________E-MAIL ADDRESS____________________________ LAW SCHOOL ATTENDED______________________________________________________ DATE OF GRADUATION________________________________________________________ DATE OF ADMISSION TO NEW YORK STATE BAR (AND ANY OTHER STATE(S) ADMITTED (WITH DATES) ______________________________________________________________________________ ______________________________________________________________________________ _______________________________________________________________________________ DATE OF ADMISSION TO THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF NEW YORK ______________________________________________________ OTHER DISTRICT/CIRCUIT COURTS ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ How many Federal criminal cases have you handled during the last five years?________________ (a) Of these Federal criminal cases, indicate the extent of your involvement. (i) Investigation stage only_______________________________________________ -1American LegalNet, Inc. www.USCourtForms.com (ii) Pleas of guilty_______________________________________________________ -2American LegalNet, Inc. www.USCourtForms.com (iii) Trials to verdict_____________________________________________________ (a) (b) (iv) Jury_________________________________________________________ Non-jury_____________________________________________________ Other disposition (indictment dismissed, etc.) ______________________________________________________________________________ ______________________________________________________________________________ _______________________________________________________________________________ Other relevant experience (e.g., State Court, Criminal and Civil Cases, Federal Civil Cases). Attach additional pages, as needed. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ List the names of all Federal Judges in the Eastern District of New York before whom you have conducted a litigated motion or a trial over the last five(5) years, and give the names of the cases: Name of Judge Name of Case ______________________________________________________________________________ _______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ List the names, addresses and telephone numbers of five adversaries in Federal criminal cases which you have handled. Also indicate the names of the cases: Name of Adversary Address and Telephone Number of Adversary Name of Case ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ -3American LegalNet, Inc. www.USCourtForms.com -4American LegalNet, Inc. www.USCourtForms.com How many Federal criminal appeals have you handled during the last five years?______________ List the five most recent petitions which you have handled before the United States Court of Appeals for the Second Circuit; indicate whether you represented the Government, or provide the name of the defendant you represented. If there was a published opinion, please provide the citation. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _______________________________________________________________________________ ________________________________________________________________________________ How many Federal and New York State habeas corpus (or coram nobis) petitions have you handled during the last five years? _________________________________________________________ (a) List the five most recent petitions which you have handled, and provide the name of the defendant you represented. If there was a published opinion, please provide the citation. ______________________________________________________________________________ ______________________________________________________________________________ _______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________________________ (b) Would you be available for assignments in habeas corpus matters? __________________ Have you been a member of any Panel for defense lawyers under the Federal Criminal Justice Act, Article 18-B, or the Appellate Division’s Homicide Panel?_____________________ (a) Indicate the Panels on which you have participated: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ -5American LegalNet, Inc. www.USCourtForms.com (b) How many cases have you been assigned under each of these Panels?_________________ (c) How many, if any, assigned cases have you been relieved from during the past five (5) years?________________________________ For what cause?___________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (d) Has your application to any assigned Panel ever been turned down? _________________ If so, please give particulars: ______________________________________________________________________________ _______________________________________________________________________________ ______________________________________________________________________________ (e) Have you ever been removed from any Panel?__________________ If so, please identify Panel, date of removal, and reason for removal: ______________________________________________________________________________ ______________________________________________________________________________ Enumerate any Federal criminal trial experience you have had prior to the last five (5) years which you feel will be helpful in evaluating your competence to serve on the Criminal Justice Act Panel: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ List other criminal trials and criminal appellate experience which you have had in other Federal Courts or in this State’s Courts. List Judges, adversaries with their addresses and telephone numbers, and names of cases. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________________________ ______________________________________________________________________________ PUBLICATIONS: Specify. -6American LegalNet, Inc. www.USCourtForms.com ______________________________________________________________________________ _______________________________________________________________________________ ______________________________________________________________________________ -7American LegalNet, Inc. www.USCourtForms.com Are you available for assignments of cases in both the Brooklyn and Central Islip courthouses? ____________ If not, specify which___________________________________________________ SPECIAL STUDIES AND FOREIGN LANGUAGE: List any special education courses including Federal Criminal Law or the new Federal Rules of Evidence which you have had in the last five years Also, state any foreign language proficiencies you may have. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 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. _______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Have you ever been the subject of a contempt proceeding? _______If so, please give particulars. ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________________________ ______________________________________________________________________________ Have you ever been the subject of a bar disciplinary proceeding?__________________________ If so, please give particulars: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ________________________________________________________________________________ ______________________________________________________________________________ I hereby agree to abide by the decisions of the Criminal Justice Act Committee on all matters, including removal from the Panel. _____________________________ DATE __________________________________________ APPLICANT -8- American LegalNet, Inc. www.USCourtForms.com Rev. 10/01 -9- American LegalNet, Inc. www.USCourtForms.com