Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Employment(06/2018) Page 1 of 4 TOP SECTION ONLY TO BE COMPLETED BY APPLICANT: (check one) 1st Dept. 2nd Dept. 3rd Dept. 4th Dept.In the Matter of the Application of þ for Admission to Practice as an Attorney and Counselor-at-Law. B þ For each law-related employment or period of solo law practice listed by applicant on the application for admission questionnaire (see question number 15), applicant must submit this original form affirmation. For a period of solo practice, this affirmation must be completed by an attorney. Unless otherwise not feasible, this affirmation should not be completed by persons related to applicant by blood or marriage. The person completing this form affirmation should return it to the applicant, who should submit it with and at the same time as application for admission questionnaire. Note to applicants applying for admission on examination: do not submit an employment affirmation for employments listed on your 50 hour pro bono compliance affidavit or listed on your pro bono scholars program completion affidavit (see instructions accompanying question 15 on the application for admission questionnaire). TO BE COMPLETED BY AFFIRMANT: þ þ þ I , , that the answers to the following questions have been written by me or under my direction; that the substance and the language have been supplied by me and not by applicant or any other person; and that both the questions and the answers have been carefully read by me, and that the several answers are true to my own knowledge, except those stated to have been made on information and belief, or which express my opinion, and as to those answers, I believe them to be true. My full mailing address is as follows: American LegalNet, Inc. www.FormsWorkFlow.com Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Employment(06/2018) Page 2 of 4 þ To be completed only by affirmants who are attorneys. I am currently admitted to practice and in good standing in the following jurisdiction(s) and was so admitted on the following dates: þ þþ þ þ þ þþ þ þ þ To be completed only by attorneys confirming a period of practice of law by applicant.(a) þ The length and nature of my acquaintance with the applicant is as follows:(b) Applicant engaged in the solo practice of law at the following address(es) during the following period(s) of time: þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ To be completed by affirmants confirming a law-related employment by applicant (.(a) þ Applicant was employed by me individually in a law-related capacity or was employed in a law-related capacity as follows:(1) þ Name and address of employer: þ þ þ þ þ þ þ þ American LegalNet, Inc. www.FormsWorkFlow.com Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Employment(06/2018) Page 3 of 4 (2) þ Beginning and ending dates of employment (or that it continues to date) (if terminated, affirmant should state how and why): þ þþ þ (3) þ Position and nature and extent of legal services performed by applicant: (b) þ My relationship with the employer and applicant during the period of employment was as follows:(1) þ My position with employer (for example, member of employing firm, head of law department of a corporation, managing attorney, etc.): (2) þ Nature and frequency of my contacts with and/or supervision, if any, of applicant (if affirmant did not supervise applicant, affirmant should provide name and position of supervisor): American LegalNet, Inc. www.FormsWorkFlow.com Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Employment(06/2018) Page 4 of 4 þ No If I hereby provide any other facts within my knowledge, or of which I have information, which in my opinion have any I affirm under the penalties of perjury under the laws of New York, with the knowledge that false statements made herein are punishable under section 210.45 of the Penal Law, which may include a fine or imprisonment that the foregoing is true and accurate to the best of my knowledge, and I understand that this document will be filed with Dated American LegalNet, Inc. www.FormsWorkFlow.com