APPLICATION FOR ADMISSION TO PRACTICE AS AN ATTORNEY AND COUNSELOR-AT-LAW IN THE STATE OF NEW YORK FORM AFFIDAVIT AS TO APPLICANT'S COMPLIANCE WITH THE PRO BONO REQUIREMENTS, INCLUDING CERTIFICATION BY SUPERVISOR INSTRUCTIONS All applicants for admission to practice as attorneys in New York State must complete at least 50 hours of lawrelated pro bono work as defined and required by Court of Appeals Rule § 520.16 prior to being admitted. Applicant must submit a form affidavit for each pro bono project that applicant is using to satisfy the 50-hour requirement and must secure the certification of the individual who supervised each project. All applicants should refer to the Frequently Asked Questions about Pro Bono Requirements (available at www.nycourts.gov/attorneys/probono/ baradmissionreqs.shtml) for further information about qualifying work. The applicant must provide the information requested on page one of the form, and then have the form notarized. After the form is notarized, the attorney who supervised the applicant's pro bono work must then complete the Supervisor Certification. To Be Certified Under Oath By Applicant: NAME OF APPLICANT addRess of applicant state zip city / town / village countRy (if not USA) PLEASE PRINT OR TYPE THIS FORM NAME OF ORGANIZATION/DEPARTMENT WHERE PRO BONO EXPERIENCE WAS COMPLETED supeRvising attoRney oRganization/depaRtment addRess state oRganization phone zip oRganization e-mail countRy (if not USA) DATES OF SERVICE: NUMBER OF HOURS COMPLETED: Legal Services Provider From (mm/dd/yyyy): . / / To (mm/dd/yyyy): / / INDICATE CATEGORY OF SERVICE by checking appropriate box below: Government Service Law School Sponsored Program Other All applicants must provide a description of the nature of the pro bono work completed. if applicant performed the pro bono work outside the united states, complete details must be included about the type of work performed, the nature of the program and where the work was performed. (Attach additional sheets if needed.) application for admission to practice as an attorney and counselor-at-law in the state of new york: Form Affidavit as to Applicant's Compliance with the Pro Bono Requirements Revised: April 2015 American LegalNet, Inc. www.FormsWorkFlow.com 1 state (country) of: ) county (city) of: ) ss.: ) i (print name of applicant), , sweaR(oRaffiRm) that the foregoing information is true and accurate to the best of my knowledge. signature of applicant: subscribed and sworn to or affirmed before me this day of in the year 20 . To Be Completed By Supervisor: * If this affidavit is sworn to outside the United States, it commonwealths, territories or possessions, and the attesting officer is not a notary public, attach a certificate of the attesting officer's authority to attest to or witness the signature of the affiant in the jurisdiction. Notary Public* (affix seal or stamp.) SUPERVISOR CERTIFICATION I HEREBY CERTIFY (a) that i have read the foregoing affidavit of compliance and (b) that the applicant has accurately described the circumstances, timing and nature of the pro bono work described therein. APPLICANT'S DUTIES WERE SATISFACTORILY PERFORMED: . . . . . . . if `no,' applicant's performance was not satisfactory in the following respects: No Yes I HEREBY PROVIDE any other facts within my knowledge, or of which i have information, which in my opinion have any bearing on applicant's qualifications and moral character or fitness to practice law, or which would be helpful to the appellate division or its committees on character and fitness in determining applicant's character and fitness. application for admission to practice as an attorney and counselor-at-law in the state of new york: Form Affidavit as to Applicant's Compliance with the Pro Bono Requirements 2 American LegalNet, Inc. www.FormsWorkFlow.com attoRney signatuRe attoRney title attoRney employeR: JuRisdiction wheRe admitted to pRactice law: e-mail addRess comments (if further explanation is necessary) pRint attoRney name date telephone application for admission to practice as an attorney and counselor-at-law in the state of new york 3 American LegalNet, Inc. www.FormsWorkFlow.com