UNITED STATES COURT OF APPEALS FOR THE SEVENTH CIRCUIT VOLUNTEER PANEL ATTORNEY QUESTIONNAIRE Name: _________________________________ E-Mail: _______________________________________ Address: ________________________________________________________________________________ _______________________________________________________________________________________ Telephone: __________________________ Social Security Number (required): ____________________ Federal Employer Identification Number (necessary for tax purposes on vouchers in Criminal Justice Act cases only) ___________________________________________ (pre-existing agreement w/ law firm or corporation) Bar Admissions: _________________________________________________________________________ Law school attended and Date of Degree _____________________________________________________ Type of practice: _________________________________________________________________________ I am conversational/fluent in the following languages: c f Spanish c f Polish c f Chinese c f Other Other languages (if more than one, please specify conversational/fluent):_______________________________________ Are you currently a member of a panel maintained by a district court or Federal Public Defender office for appointment in district court proceedings? ____ Yes ____ No If "yes", please specify: _____________________________________________________________________ _____ I am interested in accepting Criminal Justice Act appointments from the Court of Appeals, under the guidelines set forth in the Act and the Seventh Circuit Plan for implementation of the Act. I will accept appointment in the following Criminal Justice Act appeals: in ____ direct criminal appeals ____ � 2254 and ____ � 2255 and/or. ____ I am interested in accepting appointment in non-Criminal Justice Act appeals, understanding that there is no statutory authority for the court to compensate me for my time and expenses. ____ Non-prisoner civil rights ____ EEOC I will accept appointment in the following types of non-Criminal Justice Act appeals: ____ Prisoner civil rights ____ Immigration ____ Employee discrimination issues ____ Other matters: please specify: ___________________________ Signature ___________________________________ Please return this questionnaire and current resume to: Donald J. Wall, Counsel to the Circuit Executive U. S. Court of Appeals 219 South Dearborn Street, #2722 Chicago, IL 60604 don_wall@ca7.uscourts.gov rev. ( 03/2017) Date ___________________ American LegalNet, Inc. www.FormsWorkFlow.com