Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (06/2018) Page 1 of 20 Application for Admission Questionnaire - Please see the General Instructions for guidance on filing complete applications Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New YorkNew York State Supreme Court Appellate Division Application For (check one) þ Admission on Examination or Admission on Motion without ExaminationAppellate Division (check one) þ 1st Dept. 2nd Dept. 3rd Dept. 4th Dept. To the Appellate Division of the Supreme Court of the State of New York: The undersigned hereby applies for admission to practice as an attorney and counselor-at-law in all courts of the State of New York, and in support of such application submits the following sworn statement and the accompanying affidavits and other papers. A. þ Personal Information 1. þ State name in full: First þ Middle þ þ Last þ Suffix (Jr., III) þ þ 2. þ Have you ever used or been known by any other name? No YesIf , state in full each name (other than the name given above) which you have used or by which you have at any time been known, the period of, and the reason for, the use of each such name; if change of name is by marriage, so state; if change of name was by court order, so state.Full Name þ Reason for change þ þ Full Name þ Reason for change þ þ 3. þ United States Social Security number (if any): 226 226 4. þ BOLE ID# (NYS Board of Law Examiners Identification Number): B þ 5. þ State the following: Age: Date of Birth (mm/dd/yyyy): / / Place of Birth (City/Town/Village) þ State þ Country þ þ 6. þ Are you a citizen of the United States? No YesNo þ 7. þ Present residence (full mailing address):Street Address þ þ City/Town/Village þ State þ ZIP þ Country (if not USA) þ Telephone þ E-mail (if any) þ þ Pro Bono Scholars Program American LegalNet, Inc. www.FormsWorkFlow.com Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (06/2018) Page 2 of 20 8. Prior residence (provide the last permanent residence where you resided before the address in question 7):Period From (Month/Year): / To (Month/Year): /Street Address City/Town/Village State þ ZIP þ Country (if not USA) 9. Office address (if applicable): City/Town/Village State þ ZIP Country (if not USA) Telephone þ E-mail (if any) B. Education10. List all colleges, universities and professional schools (other than law schools) attended. Provide a chronologicallisting (from earliest to latest). If you did not receive a degree, state the reason. Dates of Attendance From (Month/Year): / To (Month/Year): / Name of College / University / Other Degree Street Address City/Town/Village State ZIP Country (if not USA) Reason for not receiving a degree (if applicable) Dates of Attendance From (Month/Year): / To (Month/Year): / Name of College / University / Other Degree Street Address City/Town/Village State ZIP Country (if not USA) Reason for not receiving a degree (if applicable) Dates of Attendance From (Month/Year): / To (Month/Year): / Degree Street Address City/Town/Village State ZIP Country (if not USA) Reason for not receiving a degree (if applicable) American LegalNet, Inc. www.FormsWorkFlow.com Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (06/2018) Page 3 of 20 11. List all law schools attended. Provide a chronological listing (from earliest to latest). If you did not receive a degree,state the reason.Form Law School Certificates: You must send the Form Law School Certificate to each law school listedbelow. Each law school should return the form directly to the Appellate Division. Dates of Attendance From (Month/Year): / To (Month/Year): / Name of Law School Degree Street Address City/Town/Village State ZIP Country (if not USA) Reason for not receiving a degree (if applicable) Dates of Attendance From (Month/Year): / To (Month/Year): / Name of Law School Degree Street Address City/Town/Village State ZIP Country (if not USA) Reason for not receiving a degree (if applicable) Note: If you answer to question 12, 13 or 14, give the name of the institution, and state fully the circumstances and date of each such occurrence.12. Have you ever been denied admission to any school, college, law school, or other similar institution for stated causewhich might reflect upon your character? No Yes (if 223Yes224 answer below) Name of Institution Date Reason and Circumstances: 13. Have you ever been placed on probation, dropped, suspended, expelled or otherwise been subjected to disciplineby any institution of learning above elementary school level for conduct which might reflect upon your character? No Yes (if 223Yes224 answer below) Name of Institution Date Reason and Circumstances: American LegalNet, Inc. www.FormsWorkFlow.com Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (06/2018) Page 4 of 20 14. Have you ever been requested or advised by any college, law school, or other professional or graduate school forany reason to discontinue your studies therein? No Yes (if 223Yes224 answer below) Name of Institution Date Reason and Circumstances: C. Employment List every employment you have had since you reached the age of 21, or in the last 10 years, whichever periodis shorter, in chronological order (from earliest to latest). Include your current employment, if any. Include self-employment, clerkships, temporary or part-time employment, military service, employment by members of family orother relatives, employment with or without monetary compensation, law-related work-study employment, and law-related employment for academic credit only, including participation in law school clinics and externships, and work asa research assistant. Note to applicants applying for admission on examination: do not include employments listed onyour 50 hour pro bono compliance affidavit or listed on your pro bono scholars program completion affidavit. For each law-related employment or period of solo law practice listed in reply to this question, please submit an original formaffirmation. If you have not had any law-related employment, submit a letter addressed to the Appellate Divisionon the letterhead of your present employer, or if you are not presently employed, from your last employer, givingthe nature of the services you rendered, (b) the period of employment, (c) the reason you left, and (d) abrief evaluation of your character. Note to applicants applying for admission on examination: do not submit anemployment affirmation for employments listed on your 50 hour pro bono compliance affidavit or listed on yourpro bono scholars program completion affidavit. Period From (mm/yyyy) To (mm/yyyy) þ Name of Employer Position(s) Held þ þ City/Town/Village State ZIP Country (if not USA) Telephone Reason for Leaving or Termination: American LegalNet, Inc. www.FormsWorkFlow.com Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (06/2018) Page 5 of 20 Period From (mm/yyyy) þ To (mm/yyyy) þ Name of Employer þ Position(s) Held þ þ City/Town/Village þ State þ ZIP þ Country (if not USA) þ Telephone þ þ Reason for Leaving or Termination: Period From (mm/yyyy) þ To (mm/yyyy) þ Name of Employer þ Position(s) Held þ þ City/Town/Village þ State þ ZIP þ Country (if not USA) þ Telephone þ þ Reason for Leaving or Termination: Period From (mm/yyyy) þ To (mm/yyyy) þ Name of Employer þ Position(s) Held þ þ City/Town/Village þ State þ ZIP þ Country (if not USA) þ Telephone þ þ Reason for Leaving or Termination: American LegalNet, Inc. www.FormsWorkFlow.com Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (06/2018) Page 6 of 20 Period From (mm/yyyy) To (mm/yyyy) þ Name of Employer Position(s) Held þ þ City/Town/Village State ZIP Country