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Application For Admission To Practice As Attorney And Counselor-At-Law (Forms) Form. This is a New York form and can be use in Attorneys Statewide.
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APPLICATION FOR ADMISSION TO PRACTICE
AS AN ATTORNEY AND COUNSELOR-AT-LAW IN THE
STATE OF NEW YORK1
APPLICATION FOR ADMISSION QUESTIONNAIRE
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. PERSONAL INFORMATION
1. (a) State name in full________________________________________________________
(First)
(Middle)
(Last)
(b) Have you ever used or been known by any other name? _________________________
If so, state in full each name (other than the name above given) which you have used or
by which you have at any time been known, the period of, and the reasons 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.
______________________________________________________________________________
______________________________________________________________________________
(c) Social Security number ___________________________________________________
2. State the following:
(a) Age, date, and place of birth _______________________________________________
(b) Are you a citizen of the United States?_______________________________________
If you are not a citizen of the United States, state your immigration status. _____________
______________________________________________________________________________
3. Present residence (full mailing address).
______________________________________________________________________________
_________________________________________________________________________________
.
(residence telephone) ____________________________________________________________
1. Please check one of the following: this is an application for Admission on Examination ___ or
Admission on Motion without Examination ___. Ple ase see the General Instructions for
guidance on filing complete applications.
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Office address (if applicable) (full mailing address).
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(office telephone) _______________________________________________________________
E-mail address (if any) ___________________________________________________________
4. Prior residences.
List all prior temporary and permanent residences since you reached the age of 21 or during
the past ten years, whichever period is shorter. Include college residences, military addresses, and
temporary residences of more than six months duration away from home for educational, business
or other special purposes. Provide a chronological continuous residence listing (from earliest to
latest) without interruption.
Period: From Month/Year
To Month/Year__________________________
Address (street and number) _______________________________________________________
City, Village or Town, and County __________________________________________________
State and Country __________________________________________ Zip Code _____________
***
Period: From Month/Year __________________ To Month/Year _________________________
Address (street and number) _______________________________________________________
City, Village or Town, and County __________________________________________________
State and Country __________________________________________ Zip Code ____________
***
Period: From Month/Year ___________________ To Month/Year ________________________
Address (street and number) _______________________________________________________
City, Village or Town, and County __________________________________________________
State and Country __________________________________________ Zip Code _____________
***
Period: From Month/Year ___________________ To Month/Year ________________________
Address (street and number)
City, Village or Town, and County __________________________________________________
State and Country __________________________________________ Zip Code _____________
B. EDUCATION
5. List all colleges, universities and professional schools (including law schools) attended.
If you did not receive a degree, state the reason.
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FORM LAW SCHOOL CERTIFICATES: For each law school listed, send the law school
the form law school certificate which the law school should complete and return directly to the
Appellate Division.
***
College _________________________________ Degree ________________________________
Address _______________________________________________________________________
City ____________________________________State or Country ________________________
Dates of Attendance: From __________________________ To ___________________________
***
College _________________________________ Degree ________________________________
Address _______________________________________________________________________
City ____________________________________State or Country ________________________
Dates of Attendance: From ____________________________To _________________________
***
Law School _____________________________ Degree ________________________________
Address________________________________________________________________________
City ____________________________________State or Country_________________________
Dates of Attendance: From __________________________ To___________________________
***
Law School _____________________________ Degree ________________________________
Address _______________________________________________________________________
City
State or Country
Dates of Attendance: From___________________________ To __________________________
***
6. (a) Have you ever been denied admission to any school, college, law school, or other
similar institution for stated cause which might reflect upon your character? ________________.
(b) Have you ever been placed on probation, dropped, suspended, expelled or otherwise
been subjected to discipline by any institution of learning above elementary school level for conduct
which might reflect upon your character? ____________________________________________.
(c) Have you ever been requested or advised by any college, law school, or other
professional or graduate school for any reason to discontinue your studies therein? ___________.
If your answer is "Yes" to (a), (b) and/or (c), give the name of any such institution and state
fully the circumstances and date of each such occurrence. ________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
C. EMPLOYMENT
7. (a) List every employment you have had since you reached the age of 21, in chronological
order (from earliest to latest). Include self-employment, clerkships, temporary or part-time
employment, military service, employment by members of family or other relatives, employment
with or without monetary compensation, law-related work-study employment, and law-related
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employment for academic credit only.
FORM AFFIDAVITS AS TO APPLICANT'S LAW-RELATED EMPLOYMENT AND/OR
SOLO PRACTICE: For each law-related employment or period of solo law practice listed in reply
to this question, please submit a form affidavit. If you have not had any substantial law-related
employment, submit a letter addressed to the Appellate Division on the letterhead of your present
employer, or if you are not presently employed, from your last employer, giving (a) the nature of
the services you rendered, (b) the period of employment, (c) the reason you left, and (d) a brief
evaluation of your character.
Period: From Month/Year___________________ To Month/Year ________________________
Name of Employer ______________________________________________________________
Employer's Address _____________________________________________________________
City_____________________________________ State/Country____________ Zip ___________
Employer's Telephone ____________________________________________________________
Nature of Employer's Business _____________________________________________________
Position or Positions Held____________________________________________________________
Reason for Leaving or Termination _________________________________________________
______________________________________________________________________________
***
Period: From Month/Year___________________ To Month/Year ________________________
Name of Employer ______________________________________________________________
Employer's Address
City _____________________________________State/Country_____________Zip__________
Employer's Telephone ____________________________________________________________
Nature of Employer's Business _____________________________________________________
Position or Positions Held ________________________________________________________
______________________________________________________________________________
Reason for Leaving or Termination_
***
Period: From Month/Year_____________________ To Month/Year_______________________
Name of Employer ______________________________________________________________
Employer's Address _____________________________________________________________
City
State/Country
Zip
Employer's Telephone ____________________________________________________________
Nature of Employer's Business _____________________________________________________
Position or Positions Held _________________________________________________________
______________________________________________________________________________
Reason for Leaving or Termination
***
Period: From Month/Year______________________ To Month/Year______________________
Name of Employer ______________________________________________________________
Employer's Address ______________________________________________________________
City
State/Country
Zip
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Employer's Telephone
Nature of Employer's Business
Position or Positions Held _________________________________________________________
______________________________________________________________________________
Reason for Leaving or Termination
______________________________________________________________________________
***
Period: From Month/Year_______________________ To Month/Year _____________________
Name of Employer ______________________________________________________________
Employer's Address ______________________________________________________________
City
State/Country
Zip
Employer's Telephone
Nature of Employer's Business _____________________________________________________
Position or Positions Held _________________________________________________________
______________________________________________________________________________
Reason for Leaving or Termination _________________________________________________
______________________________________________________________________________
***
(b) Are you now, or have you ever been engaged on your own account or with others in any
occupation, business, or profession, other than law, in the State of New York or elsewhere?
_____________________________________________________________________________.
If so, give in detail the nature and location thereof and the month and year of the beginning
and ending of your engagement in or connection therewith. If any such business was carried on by
you in partnership with others, give the names and addresses of all partners and the nature of the
business. If the business was carried on by a corporation in which you held any office state its name,
address, nature of the business and your connection with it. ______________________________
_________________________________________________________________________________
______________________________________________________________________________
____________________________________________________________________________.
List any action now pending against such firm or corporation and any judgment entered
against it during the period of your association with it. ___________________________
______________________________________________________________________________
_______________________________________________________________________________
_____________________________________________________________________________.
8. In connection with any employment, have you ever been discharged or requested to resign
from or leave your position for cause? _______________________________________________.
If your answer is "Yes", give the name of each such employer and state the date and
circumstances as to each such incident.______________________________________________
_____________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
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D. BAR ADMISSIONS
9. (a) Have you ever applied for admission to the Bar of the State of New York in this or
any other Department (see CPLR § 9405), including admission pro hac vice (see Rules of Court of
Appeals § 520.11)? _____________________________________________________________.
(b) Have you ever engaged in or has your conduct ever been called into question with
reference to the unauthorized practice of law? _______________________________________.
(c) Have you ever been employed by or otherwise connected with any person, firm or
corporation who or which, to your knowledge, engaged in conduct that was called into question on
the subject of unauthorized practice of law while you were so employed or connected?_________.
(d) Except for activities comprising part of a law school clinical program or otherwise
permitted by law (see Judiciary Law §§ 478, 484, 495), have you ever tried any action or
proceeding, argued any motion, drawn legal papers other than under the supervision of an attorney,
given legal advice or held yourself out as an attorney in this State? ________________________.
If your answer is "Yes" as to any part of this question, state the matter fully.___________
.
10. (a) Have you ever applied to take or taken the Bar examination in any country, state or
jurisdiction other than the State of New York? ________________________________________.
(b) Have you ever applied for admission to practice as an attorney in any country, state
or jurisdiction other than the State of New York? ______________________________________.
If your answer to (a) or (b) is "Yes", state specifically the disposition made of the application
or the result of the Bar examination. If admitted, state the name of each jurisdiction and court by
which admitted and the date of such admission.
______________________________________________________________________________
.
Applicants admitted in other States or countries must attach (1) an original copy of a
certificate of admission and good standing at the Bar from each such jurisdiction and (2) a letter
from each such jurisdiction's grievance committee, or other body entertaining complaints against
lawyers, where available, certifying as to whether charges have been filed with such committee or
body against you, and, if so, the substance of the charges and the disposition thereof. Certificates
of good standing and grievance letters should not be dated more than 60 days prior to submission.
E. MILITARY RECORD
11. (a) Have you at any time or in any manner served in any of the armed forces of the
United States, including reserves? _______________. If the answer is "Yes", state (1) when, where,
and which service; (2) period and nature of service rendered; and (3) if discharged, give date and
nature of discharge.
.
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(b) Have you served in the armed forces (reserves or otherwise) of any country other
than the United States of America? _________. If the answer is "Yes", give name of country,
inclusive dates of service, and reason for separation from service. ___________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
(c) As a member of any armed forces, have you been the subject of any charge, or have
any proceedings been instituted against you, or have you been a defendant in any court martial
proceeding? _________. If answer is "Yes", state the facts. _______________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
F. CRIMINAL RECORD
12. Have you ever, either as an adult or a juvenile, been cited, arrested, taken into custody,
charged with, indicted, convicted or tried for, or pleaded guilty to, the commission of any felony or
misdemeanor or the violation of any law, except minor parking violations, or been the subject of any
juvenile delinquency or youthful offender proceeding? YES___ NO___. If you answer yes, state
the charge or charges, the disposition thereof and the underlying facts. Although a conviction may
have been expunged from the records by an order of a court, it nevertheless should be disclosed in
the answer to this question. Please note that you should have available and be prepared to submit
or exhibit copies of police and court records regarding any matter you disclose in reply to this
question. ______________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
G. CIVIL MATTERS
13. State whether you have
(a) ever testified, refused to testify, or been granted immunity, as a witness in any action or
proceeding, or before any prosecuting or investigative agency in any matter. ________________.
(b) ever failed to answer any ticket, summons or other legal process served upon you at any
time. _______. If so, was any warrant, subpoena or further process issued against you as a result
of your failure to respond to such legal process? _______. State the number of unpaid traffic
tickets, if any, in your name or attributable to a motor vehicle registered in your name, and the
respective fines due thereon. ______________________________________________________.
(c) any mental or emotional condition or substance abuse problem that could adversely
affect your capability to practice law? ________. Are you currently using any illegal
drugs?_________________________________________________________________________.
(d) ever been charged with fraudulent conduct or any other act involving moral
turpitude._______________________________________________________________________.
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(e) ever been a party to or otherwise involved in any civil or criminal action, proceeding or
investigation not covered by answers to the foregoing subdivisions of this question.
______________________________________________________________________________.
If your answer is "Yes" to any subdivision of this question, indicate the subdivision and state
the facts as fully as possible. If applicable, provide the name and locality of the court or agency, the
approximate date of the action or proceeding, and the judgment or other disposition.
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
H. CHILD SUPPORT
14. As of the date this application for admission is filed, I AM/ I AM NOT (circle the
applicable words) under an obligation to pay child support. If you circle "I AM", answer YES or
NO to the following statements:
a. I am not four months or more in arrears in the payment of child support. ___________
b. I am making payments by income execution or by court agreed payment or repayment
plan or by plan agreed to by the parties. _____________________________________
c. The child support obligation is the subject of a pending court proceeding. ___________
d. I am receiving public assistance or supplemental security income. _________________
If you answer "YES" to at least one of the above four statements, you may be admitted.
If you answer "NO" to all four statements, please explain below. ___________________
______________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
PLEASE NOTE THAT PERSONS WHO ARE FOUR MONTHS OR MORE IN
ARREARS IN CHILD SUPPORT OR WHO HAVE FAILED TO COMPLY WITH A
SUMMONS, SUBPOENA OR WARRANT RELATING TO A PATERNITY OR CHILD
SUPPORT PROCEEDING MAY BE SUBJECT TO SUSPENSION OF THEIR BUSINESS,
PROFESSIONAL, DRIVERS' AND/OR RECREATIONAL LICENSES AND PERMITS
INCLUDING, BUT NOT LIMITED TO, LICENSES ISSUED PURSUANT TO
ENVIRONMENTAL CONSERVATION LAW § 11-0713.
Please further note that the intentional submission of false written statements for the purpose
of frustrating or defeating the lawful enforcement of support obligations is punishable pursuant to
section 175.35 of the Penal Law of the State of New York.
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I. FINANCIAL MATTERS / DEFAULTS
15. (a) Are there any unsatisfied judgments against you? _________. If so, list the same
giving name and address of judgment creditor and the court by which judgment was rendered,
together with the date and amount thereof and the nature of the claim on which it was
based._________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.
(b) Are you in default in the performance or discharge of any duty or obligation imposed
upon you by a judgment, decree, order or directive of any court or governmental agency? ________.
If so, state the facts.
.
(c) Do you owe any debt for $300.00 or more, which is past due for over 90 days?
_________. If so, list each such debt and state the name and address of the creditor, the amount
presently owed, the due date, and the nature of the debt. ________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.
(d) Have you ever applied for or been granted a discharge in bankruptcy?
state the facts.
. If so,
.
(e) Do you have any loan made or guaranteed by the New York State Higher Education
Services Corporation currently outstanding? _________________. If so, state whether you are
presently in default on any such loan and, if you are presently in default, state the name and address
of the creditor, the amount presently owed, the due date, and the nature of the default.
______________________________________________________________________________
______________________________________________________________________________
.
J. LICENSES / BONDS
16. (a) Have you ever applied for a license the procurement of which required proof of good
character (other than Bar applications listed under question number 10 above)? _______. If granted,
state, as to each such license, the approximate date it was granted and the name of the authority
granting it._____________________________________________________________________
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.
(b) If your application for such a license was not granted, state the facts.
.
(c) If any such license was revoked, state the facts.
.
17. Has anyone ever sought to recover on or cancel a fidelity bond on account of your
conduct in connection with a bonded position held by you?
. If so, specify the nature of
your position, the dates during which you were bonded, and the underlying circumstances.
.
K. LOYALTY / OATHS /CODE OF PROFESSIONAL RESPONSIBILITY
18. Have you ever organized or helped to organize or become a member of any organization
or group of persons which, during the period of your membership or association, you knew was
advocating or teaching that the government of the United States or any state or any political
subdivision thereof should be overthrown or overturned by force, violence or any unlawful means?
. If your answer is in the affirmative, state the facts below.
.
19. Is there any reason why you cannot take and subscribe to an oath or affirmation that you
will support the Constitutions of the United States and of the State of New York?
. If
there is, please explain.
.
20. Can you conscientiously, and do you, affirm that you are without any mental reservation,
loyal to and ready to support the Constitution of the United States?
.
21. (a) Have you read the Rules of Professional Conduct adopted by the Appellate Division
(see, 22 NYCRR Part 1200)?
.
(b) Will you conscientiously endeavor to conform your professional conduct to them?
.
***
Since this is a continuing application, I will submit such additional affidavits, papers
or information as may be requested or as may be necessitated by any change in my situation
up to the date of my appearance before the Appellate Division to be sworn in as an attorney
and counselor-at-law.
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STATE (COUNTRY) OF ________________)
________________)ss.:
COUNTY (CITY) OF ________________)
I, __________________________________, being duly sworn, say: I have read the
foregoing questions and have fully, truthfully and accurately answered the same. The foregoing
answers are true of my own knowledge, except if stated to be made upon information and belief, and
as to such answers, I believe them to be true.
Signature of applicant _________________________________________
Dated __________________________________________
Subscribed and sworn to or affirmed before me this
day of
, 20
.
______________________________________
Notary Public
(Affix seal or stamp.)
(If application questionnaire is sworn to outside the United States, its commonwealths, territories,
or possessions, attach certificate of attesting officer's authority.
***
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ADDENDUM: DESIGNATION OF AGENT
This designation should be completed only by applicants who do not reside and are not
employed full time in the State of New York (see, 22 NYCRR 520.13).
I, _________________________________________________, do hereby appoint the Clerk
of the Appellate Division, ______ Judicial Department2, as my agent upon whom process may be
served with like effect as if served upon me personally, in any action or proceeding hereafter brought
against me and arising out of or based upon any legal services rendered or offered to be rendered
by the undersigned in the State of New York.
______________________________
Signature of Applicant
______________________________
Date
STATE (COUNTRY) OF _________________)
_________________)ss:
COUNTY(CITY) OF
_________________)
On the _____ day of __________ in the year 20___ before me, the undersigned, personally
appeared __________________________, personally known to me or proved to me on the basis of
satisfactory evidence to be the individual whose name is subscribed to the above designation of
agent and acknowledged to me that he or she executed the same, and that by his or her signature on
the designation of agent he or she executed the designation of agent.
________________________________________________
Officer qualified to administer oath
(Notary Public)
(Affix seal or stamp)
Revised 10/02
2
List the Appellate Division Department in which you are being admitted.
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APPLICATION FOR ADMISSION TO PRACTICE
AS AN ATTORNEY AND COUNSELOR-AT-LAW IN THE
STATE OF NEW YORK
FORM AFFIDAVIT AS
TO APPLICANT’S LAW-RELATED
EMPLOYMENT AND/OR SOLO PRACTICE
NEW YORK STATE SUPREME COURT
APPELLATE DIVISION
In the Matter of the Application of
___________________________________
(name of applicant)
for Admission to Practice as an
Attorney and Counselor-at-Law.
INSTRUCTIONS
For each law-related employment or period of solo law practice listed by applicant on the
application for admission questionnaire (see question number 7), applicant must submit this form
affidavit. For a period of solo practice, this affidavit must be completed by an attorney. Unless
otherwise not feasible, this affidavit should not be completed by persons related to applicant by
blood or marriage. The person completing this form affidavit should return it to the applicant who
should submit it with and at the same time as his or her application for admission questionnaire.
***
STATE (COUNTRY) OF ______________)
______________) SS.:
COUNTY (CITY) OF ______________)
I, ___________________________ (name of affiant), being duly sworn, depose and say that
the answers to the following questions have been written by 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.
1. My home and office addresses (full mailing addresses) are as follows:
Home address ________________________________________________________________
____________________________________________________________________________
City _________________________ State/Country______________________ Zip__________
Telephone____________________________________________________________________
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Office address ________________________________________________________________
____________________________________________________________________________
City __________________________ State/Country______________________ Zip_________
Telephone____________________________________________________________________
Office e-mail address (if any) ____________________________________________________
2. This question to be completed only by affiants 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:
Jurisdiction _________________________________ Year of Admission _________________
Jurisdiction ________________________________ Year of Admission _________________
Jurisdiction ________________________________ Year of Admission _________________
3. This question to be completed only by attorneys confirming a period of solo practice of law by
applicant.
(a) 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:
Address ____________________________________________________________________
___________________________________________________________________________
City __________________________ State/Country_____________________ Zip _________
From ___________________________________ To _____________________________
Address ____________________________________________________________________
___________________________________________________________________________
City __________________________ State/Country_____________________ Zip _________
From ___________________________________ To ________________________________
4. This question to be completed by affiants confirming a law-related employment by applicant (not
solo practice).
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(a) Applicant was employed by me individually in a law-related capacity or was employed in
a law-related capacity as follows:
(1) Name and address of employer:
Name ____________________________________________________________________
Address __________________________________________________________________
City _________________________State/Country _____________________ Zip _________
(2) Beginning and ending dates of employment (or that it continues to date) (if terminated,
affiant should state how and why): _____________________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________________________.
(3) Position and nature and extent of legal services performed by applicant: ____________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________________________.
(b) My relationship with the employer and applicant during the period of employment was as
follows:
(1) My position with employer (for example, member of employing firm, head of law
department of a corporation, managing attorney, etc.): _______________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
_________________________________________________________________________.
(2) Nature and frequency of my contacts with and/or supervision, if any, of applicant (if
affiant did not supervise applicant, affiant should provide name and position of supervisor):
________________________________________________________________________
________________________________________________________________________
__________________________________________________________________________.
(c) Applicant's duties were satisfactorily performed: YES ___ or NO ___; if not, applicant's
performance was not satisfactory in the following respects ______________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
_____________________________________________________________________________.
5. I hereby provide any other facts within my knowledge, or of which I have information, which in
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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 .__________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________________.
__________________________________________
Signature of Affiant
__________________________________________
Date
Subscribed and sworn to or affirmed before
me this _____ day of __________, 20 __.
_____________________________________
Notary Public
(Affix seal or stamp.)
(If affidavit is sworn to outside the United
States, its commonwealths, territories, or
possessions, attach certificate of attesting
officer's authority.)
(If this affidavit is not in English, it must be
accompanied by a duly authenticated English
translation.)
Revised 6/06
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APPLICATION FOR ADMISSION TO PRACTICE
AS AN ATTORNEY AND COUNSELOR-AT-LAW IN THE
STATE OF NEW YORK
FORM LAW SCHOOL CERTIFICATE
INSTRUCTIONS
Applicant must complete the first portion of this form certificate and send the form to each
law school listed by the applicant on his or her application for admission questionnaire (see question
number 5).
The law school should complete the remainder of the form and return it directly to the
Appellate Division Department designated below by the applicant.
Completion and submission of this form is a prerequisite to applicant's admission to the New
York State Bar.
TO BE COMPLETED BY APPLICANT:
Name of applicant: ______________________________________________________________
Applicant's current address (office or home) __________________________________________
______________________________________________________________________________
City_____________________________________ State __________________ Zip ___________
Telephone _____________________________________________________________________
E-mail (if any) __________________________________________________________________
Social security number: ___________________________________________________________
Name of law school: ____________________________________________________________
Address of law school:___________________________________________________________
City
State
Zip
Dates of attendance at law school: __________________________________________________
______________________________________________________________________________
Date graduated from law school: ___________________________________________________
Degree conferred by law school: ___________________________________________________
AUTHORIZATION BY APPLICANT: I, ________________________________, hereby authorize
________________________________________ (name of law school) and persons issuing this
certificate to release to the Appellate Division of New York State all information, files or records
requested by it or its Committees on Character and Fitness in connection with the processing of my
application for admission to the Bar of the State of New York.
Dated: _______________, 20___.
_____________________________
(Signature of Applicant)
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DESIGNATION OF APPELLATE DIVISION DEPARTMENT TO WHICH LAW SCHOOL
SHOULD MAIL COMPLETED FORM (applicant must check one of the following):
FIRST JUDICIAL DEPARTMENT: Committee on Character and Fitness, Appellate
Division, First Department, 41 Madison Avenue, 26th Floor, New York, New York 10010.
SECOND JUDICIAL DEPARTMENT: Executive Secretary, Committees on Character
and Fitness, Appellate Division, Second Department, 335 Adams Street, Room 2404, Brooklyn,
New York 11201.
THIRD JUDICIAL DEPARTMENT: Admissions Office, Appellate Division, Third
Department, P.O. Box 7350, Capitol Station, Albany, New York 12224.
FOURTH JUDICIAL DEPARTMENT: Admissions Office, Appellate Division, Fourth
Department, Suite 200, 50 East Avenue, Rochester, New York 14604.
TO BE COMPLETED BY LAW SCHOOL:
Please confirm whether or not the law school information provided by applicant above is accurate:
YES
NO If NO, please explain:
.
Was applicant charged with any misconduct, or disciplined, suspended, or dropped for any
YES
NO If so, please state fully:
misconduct?
.
Is there any other discreditable information in the personnel or other records of the law school
regarding the applicant's conduct or activities or bearing upon applicant's character not otherwise
YES
NO. If so, please state fully:
set forth in this form certificate?
.
If applicant filed a questionnaire or written application containing data about himself or herself,
please supply a copy thereof, if available.
Dated
, 20
.
Official Seal of
Law School:
Official Signature
Title
(If form is not in English, it must be accompanied by a duly authenticated English translation.)
Revised 06/09
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