New York State Continuing Legal Education Board 25 Beaver Street, Room 888, New York, NY 10004 • Phone: (212) 428-2105 Fax: (212) 428-2974 • Web site: www.nycourts.gov/attorneys/cle • E-mail: cle@courts.state.ny.us APPLICATION FOR (check one) WAIVER or MODIFICATION OF THE CLE REQUIREMENT The CLE Board may grant a waiver or modification of the CLE requirement based upon undue hardship or extenuating circumstances. Please note that waivers and modifications do not exempt you from the responsibility of filing your Attorney Registration form in a timely manner and paying the required fee. Note: All members of the NYS Bar are presumed to be practicing law in New York. If you do not practice law in New York, you may be exempt from the CLE requirement. If you practiced for part of a CLE reporting cycle, you may have a prorated requirement. (For additional information, visit the CLE Web site.) Please type or print clearly. Check one: [ ] Ms. [ ] Mr. Name: Street Address: City/State/Zip: Telephone: Fax: E-mail: Attorney Registration #: Date of Birth: Date Admitted to the New York Bar: Do you practice law in New York? (Check one) Yes No Have you been practicing law in another jurisdiction for at least five of the last seven years? Yes No CLE reporting cycle for which you are seeking a waiver/modification: On the next page, please describe the undue hardship or extenuating circumstances that have prompted your request. Please also list the courses you have taken and the number and categories of credit you have completed, and include any other relevant information. (Please note that your application will not be processed without this information.) Signature: Date: [ ] Application Returned/Incomplete - You must submit: Application Withdrawn [ ] You indicated in your application that throughout the relevant CLE reporting cycle, you: [ ] did not practice law in New York [ ] were retired from the practice of law [ ] were a full-time member of the military on active duty Therefore, please visit the CLE Web site for details regarding an exemption from the CLE requirement. If you determine that you are not exempt, please see the CLE Board's determination below. The CLE Board’s determination is as follows: [ ] Waiver Granted Waiver Denied [ ] Modification Denied [ ] Modification Granted, as follows: Extension Granted (instead of Waiver or Modification). You must complete your CLE requirement by the following date: [ ] Attorney Registration CLE Update Form enclosed (Once you fulfill your CLE requirement, determine that you are exempt or are granted a waiver complete the appropriate section and return to the address on the form.) For Office Use Only: Date: This application will be returned to you with the CLE Board’s determination indicated in the box above. You must retain this document with your other CLE records for at least four (4) years. Page 1 of 2 June 2011 American LegalNet, Inc. www.FormsWorkFlow.com APPLICATION FOR (check one) WAIVER or MODIFICATION OF THE CLE REQUIREMENT In the space below, please describe the undue hardship or extenuating circumstances that have prompted your request. Please also list the courses you have taken and the number and categories of credit you have completed, and include any other relevant information. Please do not submit your certificates of attendance unless specifically requested to do so.) UNDUE HARDSHIP OR EXTENUATING CIRCUMSTANCES THAT HAVE PROMPTED YOUR REQUEST: CLE COURSES TAKEN AND NUMBER AND CATEGORIES OF CLE CREDIT COMPLETED: OTHER RELEVANT INFORMATION: Page 2 of 2 June 2011 American LegalNet, Inc. www.FormsWorkFlow.com