OAO 78 (6/03) APPLICATION FOR JUDICIAL BRANCH FEDERAL EMPLOYMENT If You Need Additional Space, Continue Under Remarks Listing Item Number 1. Name (Last, First, Middle Initial) Mr Miss. Mrs. Ms. 1 a. Gender 2. Phone Number 3. Social Security Number F M 4. Present Address (Street, City, State, Zip) 5. Place of Birth City/State Foreign Country 6. Other Names Previously Used for Employment Purposes 7. Date of Birth GENERAL 8. Are you a U.S. Citizen? YES NO If not, give the Country of your citizenship 9. a. Were you ever a federal civilian employee? YES NO For highest civilian grade give: / grade step b. Are you receiving a federal annuity payment? YES NO c. Are you receiving federal severance pay? YES NO Former agency contact/tel: 10. Do you have any relatives that are Judges, Officers or emoyees of the United States Courplts? If so, give their nameositions,s, p and relationships to you. YES NO 11. Have you ever been discharged from a position or asked to resign under the threat of discharge?YESNOIf yes, explain under Remarks at the end of this form. th 12. Have you ever been convicted? YES NO (You may omit: (1) offenses committed before your 18 birthday and adjudicated under a juvenile offender law; (2ffenses adjudicated under) o a youth offender law; (3) offenses as to which the record has been expunged; (4) minor traffic violations for which you paid a fine of $100 or less) If yes, explain under Remarks at the end of this form. EDUCATION 13. a. Do you have a high school diploma or G.E.D. equivalent? YES NO If yes, Date of Completion Number of Grade Point b. Name and location of colleges or universities Dates Attended Degree Date Received Average and/or attended (including law schools) Quarter Semester scholastic standing Credit Hours Credit Hours Chief Undergraduate Subjects Quarter Semester Chief Graduate Subjects Quarter Semester c. Special skills, accomplishments, awards, honors, fraternities, sororities & societies (Specify)YESNO d.What was your scholastic standing in college/law school (Specify)? UPPER UPPER a UPPER e.Were you a member of an editorial board of law review or a moot court participant?YES NO f.Other schools or training such as trade, vocational, Armed Forces, or business. Give for each: Name and location of school, dates attended, subject studied, certificates, and any other pertinent data. MILITARY SERVICE 14. a. Have you ever served on active duty with the military?YES NO If yes, attach DD 214 member-4 copy, Notice of Separation. b. Are you retired from military service?YES NO APPLICANTS FOR LEGAL POSITIONS 15. a. Are you admitted to the Bar? YES NO If yes, list the Bar(s) to which admitted and date(s) of admission: Is your Bar membership ACTIVE INACTIVE b. Did you attend a Bar review course? YES NO List type of course: Dates Attending: From: To mm/dd/yyyy mm/dd/yyyy American LegalNet, Inc. www.USCourtForms.com>>>> 2O AO 78 Page 2 (6/03) WORK EXPERIENCE Include experience while in military service. (Start with your present position and work back 10 years. Use additional page if necessary.) A Number of hours worked Dates of Employment (month, day, year) Exact Title of Your Position per week: From: To Salary or Earnings Grade/Step Place of Employment Kind of Business or OrganizationStarting $ Per (If in federal Service) City Final $ Per State Name and Address of Employer (firm, organization, etc.) Name and Title of Immediate Supervisor Business Telephone: (Area Code and Phone Number) Number of Employees Supervised Reason for Leaving Description of Work B Number of hours worked Dates of Employment (month, day, year) Exact Title of Your Position per week: From: To Salary or Earnings Grade/Step Place of Employment Kind of Business or OrganizationStarting $ Per (If in federal Service) City Final $ Per State Name and Address of Employer (firm, organization, etc.) Name and Title of Immediate Supervisor Business Telephone: (Area Code and Phone Number) Number of Employees Supervised Reason for Leaving Description of Work REMARKS: (Use this space for continuation of answers. List the number of items being continued.) APPLICANT CERTIFICATION I certify that, to the best of my knowledge and belief, all of the information on and attached to this application is true, correct, complete and made in good faith.I understand that false or fraudulent information on or attached to this application may be grounds for not hiring me, or g firinme after I begin work, and maybe punishable by fine or imprisonment. I understand that any information I give may be investigated. SIGNATURE DATE SIGNED American LegalNet, Inc. www.USCourtForms.com>>>> 3O AO 78 Page 3 (6/03) WORK EXPERIENCE CONTINUATION SHEET - AO 78 C Number of hours worked Dates of Employment (month, day, year) Exact Title of Your Position per week: From: To Salary or Earnings Grade/Step Place of Employment Kind of Business or OrganizationStarting $ Per (If in federal Service) City Final $ Per State Name and Address of Employer (firm, organization, etc.) Name and Title of Immediate Supervisor Business Telephone: (Area Code and Phone Number) Number of Employees Supervised Reason for Leaving Description of Work D Number of hours worked Dates of Employment (month, day, year) Exact Title of Your Position per week: From: To Salary or Earnings Grade/Step Place of Employment Kind of Business or OrganizationStarting $ Per (If in federal Service) City Final $ Per State Name and Address of Employer (firm, organization, etc.) Name and Title of Immediate Supervisor Business Telephone: (Area Code and Phone Number) Number of Employees Supervised Reason for Leaving Description of Work REMARKS: (Use this space for continuation of answers. List the number of items being continued.) APPLICANT CERTIFICATION I certify that, to the best of my knowledge and belief, all of the information on and attached to this application is true, correct, complete and made in good faith.I understand that false or fraudulent information on or attached to this application may be grounds for not hiring me, or firing me after I begin work, and maybe punishable by fine or imprisonment. I understand that any information I give may be investigated. SIGNATURE DATE SIGNED American LegalNet, Inc. www.USCourtForms.com