UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK CJA PANEL APPLICATION FORM PLEASE COMPLETE THE ATTACHED CRIMINAL JUSTICE ACT PANEL APPLICATION FORM. ~~~~~~ PLEASE RETURN THE COMPLETED FORM TO: LAWRENCE K. BAERMAN, CLERK UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK P.O. BOX 7367 100 SOUTH CLINTON STREET SYRACUSE NY 13261-7367 ATTN: Robin Smith Rev. 12/08 American LegalNet, Inc. www.FormsWorkflow.com UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK CRIMINAL JUSTICE ACT ASSIGNED COUNSEL APPLICATION FORM 1. Name: ______________________________________________________________________________________ (LAST) 2. Firm Name: (FIRST) (MIDDLE INITIAL) ____________________________________________________________________________ 3. Office Address: (CITY) (STATE) (ZIP CODE) 4. County:__________________________ NDNY Bar Roll No:_____________________________________ 5. Office Telephone No.: ( ) Fax Number: ( 6. Home Telephone No: ( ) E-Mail Address:____________________________________ 7.* Federal Tax Identification No.: __________________ ) 7A)* Social Security No.: ___________________ 8. Education: Law School:_____________________________________________________________ Date:__________ College: _____________________________ Highest Degree obtained: ___________ Date:__________ College: _____________________________ Highest Degree obtained: ___________ Date:__________ Other: _________________________________________________________________________________ 9. Dates of Admission: A) Federal Court - Northern District of New York : _________/________/_________ C) Second Ciruit: ________/________/________ B) State Court - New York State:___________/________/___________ D) Other: ________/________/________ 10. I am fluent in a foreign language(s): YES / NO 11. I am familiar with the current NDNY Local Rules: I am familiar with the current Fed.R.Crim.P.: If Yes, please Specify:______________ YES / NO YES / NO * IF USING A LAW FIRM EMPLOYER IDENTIFICATION NUMBER, YOU MUST ALSO PROVIDE YOUR SOCIAL SECURITY NUMBER American LegalNet, Inc. www.FormsWorkflow.com 12. A) Federal Trial Court Experience: 1) List below 3 recent (within the past 5 years) cases, setting forth the case name, case number, presiding Judge, opposing counsel, your role (e.g., lead counsel, second chair, etc.), the case disposition, and anything about the case that has contributed to your qualifications: a)________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ b)________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ c)_______________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 2) Describe Federal Sentencing Guidelines’ issues that you have addressed in 3 recent (within the past 5 years) cases (please include the case name and number). ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ B) State Trial Court Experience: 1) List below 3 recent (within the past 5 years) cases, setting forth the Court, case name, case number, presiding Judge, opposing counsel, your role (e.g., lead counsel, second chair, etc.), the case disposition, and anything about the case that has contributed to your qualifications: a)________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ b)________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ c)_______________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com C) Appellate Experience: (1) List below 3 recent (within the past 5 years) appeals, setting forth the name of the court, the case name, case number, opposing counsel, your role (e.g., conducted oral argument, prepared brief, drafted brief, etc.), and the primary issues: a)________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ b)________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ c)_______________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ D) Other Relevant Experience or Training Not Previously Described: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 13. I have served as a criminal prosecutor: YES / NO If “yes”, identify the office, your position(s), and dates of service. ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 14. I have been a member of a state court assigned counsel panel: YES / NO If “yes”, identify the program and the dates of your membership. _____________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com 15. Have you ever been the subject of Court discipline? YES / NO Have you ever been suspended from participation in an assigned counsel program? YES / NO If “yes” to either question, provide details. ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 16. Continuing Legal Education: A) Have you completed any courses on the Sentencing Guidelines? YES / NO Date(s) and names of CLE provider:______________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ B) Have you completed any courses on the Bail Reform Act? YES / NO Date(s) and names of CLE provider:______________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ C) Have you attended Federal Public Defender sponsored CLE programs? YES / NO (If yes, list below) Program name:_____________________________________ Program name:_____________________________________ Program name:____________________________________ _ Date attended: __________________ Date attended: __________________ Date attended: __________________ D) What other criminal CLE programs have you attended? Program name:________________________________________ Date attended: __________________ Program name:________________________________________ Date attended: __________________ Program name:________________________________________ Date attended: __________________ E) Have you participated in the Northern District CJA Training Panel - 2nd Chair Program? Date completed:___________________________________ Dated:_______________________________________________________________________________________ Signature ------------------------------------------------------------------------------------------------------------------------------------------FOR CJA PANEL COMMITTEE USE ONLY: APPROVAL RECOMMENDED ADDITIONAL TRAINING RECOMMENDED APPROVAL NOT RECOMMENDED Date: CJA Panel Committee ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------FOR BOARD OF JUDGES USE ONLY: Attorney is added to the Panel list for the following regional area of the NDNY: Albany Binghamton Syracuse Utica Watertown Date: CJA Panel Application Rev. 12/08 W:\CJA\CJA Panel Application.wpd Hon. Norman A. Mordue, Chief Judge American LegalNet, Inc. www.FormsWorkflow.com