UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK PRO BONO PANEL APPLICATION FORM PLEASE COMPLETE THE ATTACHED PRO BONO 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: Philip McBrearty American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK PRO BONO PANEL APPLICATION FORM 1) Name: _____________________________________________________________________________ (LAST) (FIRST) (MIDDLE INITIAL) 2) Firm Name: ________________________________________________________________________ 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) Education: Law School:_____________________________________________________ Date:_________ College: __________________________Highest Degree obtained: __________ Date:_________ College: __________________________Highest Degree obtained: __________ Date:_________ Other: ____________________________________________________________________________ 8) Dates of Admission : A) Federal Court - Northern District of New York : _________/________/________ B) State Court - New York State:_______/_____ _/___ ___ C) Other (Circle Circuit, Federal, State, or County, indicate name of Court or Bar, and list admission date for each): Circuit / Federal / State / County __________________________________________________ Circuit / Federal / State / County __________________________________________________ Circuit / Federal / State / County __________________________________________________ Admission Date: _______/________/________ Admission Date: _______/________/________ Admission Date: _______/________/________ 9) I am fluent in a foreign language(s): YES / NO --> If Yes, please Specify:____________ 10) I have experience in the following areas of the law (check all that apply): Civil Rights (42 USC 1983) ___ Non-Prisoner Civil Rights Contract Labor Law Tort / Personal Injury Education Law Social Security ___ Environmental ___ Bankruptcy Other Primary Area of Practice: Public Positions Held: _____________________________________________________ _______________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Northern District of New York Pro Bono Panel Application Page 2 11) Civil Case Experience: 1) Number of NDNY Federal Civil Cases:__________ (List below information on the 3 most recent) Case Number: ________CV__________ Judge:_______________ Disposition: _________________ Case Number: ________CV__________ Judge:_______________ Disposition: _________________ Case Number: ________CV__________ Judge:_______________ Disposition: _________________ 2) Number of Federal Civil Appeals handled:_______________ Dated: ____________________ ____________________________________ Signature ------------------------------------------------------------------------------------------------------------------------------FOR INTERNAL USE ONLY: Date added to Pro Bono Panel: _______________ w:\pro bono\application 9/14/2010 Attorney Adm issions Clerk: ________________________ American LegalNet, Inc. www.FormsWorkFlow.com