UNITED STATES COURT OF APPEALS FOR THE ELEVENTH CIRCUIT Application for Criminal Justice Act or Non-Criminal Justice Act Appointments This application must be accompanied by: (1) a resume; (2) a certificate of good standing issued within the previous six months from a court described in FRAP 46(a)(1); and (3) a list of all state and federal bars of which you are a member, including state bar numbers, and your status with each bar (e.g., active, inactive, retired, etc.). PERSONAL INFORMATION Name: Last 4 digits of Social Security Number: Phone: E-Mail: ADDRESS INFORMATION Office Name: Address 1: Address 2: City: DISCIPLINE INFORMATION Answer each question. If any answer is yes, provide documentation concerning the disciplinary action. YES NO 1. 2. State: Zip: Fax: Have you been previously disciplined in any way by a court or a state bar in any jurisdiction? Is there any disciplinary matter currently pending against you in any court or state bar? EXTENT OF REPRESENTATION The Court has the authority to appoint attorneys under the Criminal Justice Act, and the guidelines for those appointments are set forth in 18 U.S.C. � 3006A and in Addendum Four of the Eleventh Circuit Rules. In non-CJA cases, the Court may appoint attorneys when the interests of justice require it, and the guidelines for those appointments are set forth in Addendum Five of the Eleventh Circuit Rules. For Addendum Five appointments, only necessary expenses may be reimbursed; compensation for attorney services is not authorized. Occasionally, the Court makes pro bono appointments in cases that are not covered by either the CJA or Addendum Five. In those cases attorneys will receive no compensation for attorney services and no reimbursement for expenses. Answer each question. YES NO 1. 2. 3. Are you interested in receiving appointments under the Criminal Justice Act, under the guidelines set forth in the Act and the Eleventh Circuit Plan under the Criminal Justice Act (Addendum Four)? Are you interested in receiving appointments under Addendum Five (Non-Criminal Justice Act Counsel Appointments)? Are you willing to accept pro bono appointments for cases that are not covered by either the Criminal Justice Act or by Addendum Five, for which you will receive no reimbursement, not even for expenses? American LegalNet, Inc. www.FormsWorkFlow.com SPECIAL QUALIFICATIONS Please indicate whether you have any special qualifications, such as fluency in a foreign language or expertise in a specialized area of law, that you believe are relevant to your application. Attach a separate sheet if necessary. OATH (OR AFFIRMATION) I, do solemnly swear (or affirm) that I will conduct myself as an attorney and counselor of this court, uprightly and according to law; and that I will support the Constitution of the United States. I do further swear (or affirm) that all responses in this application, including attachments which are incorporated herein by reference, are true and correct to the best of my knowledge, information and belief. I certify that, except as otherwise noted, I am an active member in good standing of each state bar or the bar of the highest court of each state (including the District of Columbia) listed on the attached sheet, and that my license to practice law in the named state is not currently lapsed for any reason, including but not limited to retirement, placement in inactive status, failure to pay bar membership fees or failure to complete continuing education requirements. I understand that I am required to notify the clerk of this court within 14 days of any changes in the status of my state bar memberships. See 11th Cir. R. 46-7. Signature of Applicant January 2016 2 American LegalNet, Inc. www.FormsWorkFlow.com LIST OF BAR MEMBERSHIPS You must attach a list of all bars of which you are a member, including state bars and state and federal courts to which you are admitted to practice. The list must also include bar numbers (if any), the date of admission, and your status with each bar or court (e.g., active, inactive, retired, etc.). See 11th Cir. R. 46-7. You may use this page to fulfill this requirement. Name of State or Federal Bar or Court Bar Number (if any) Date Admitted Status with Bar or Court (active, inactive, retired, etc.) NOTE: This application accompanied by all required items noted above should be forwarded to: U.S. Court of Appeals, Eleventh Circuit, Attn: Attorney Discipline Clerk 56 Forsyth Street, N.W. Atlanta, GA 30303 American LegalNet, Inc. www.FormsWorkFlow.com