MONTGOMERY COUNTY COMMON PLEAS COURT GENERAL DIVISION 41 NORTH PERRY STREET DAYTON, OHIO 45422 APPLICATION FOR APPOINTED COUNSEL AND PRO BONO PROGRAMS APPLICANT INFORMATION NAME: *ATTORNEY REGISTRATION #: FIRM NAME AND ADDRESS: *TELEPHONE NUMBER(S): FAX NUMBER: *E-MAIL ADDRESS: LAW SCHOOL ATTENDED: ARE CLE CREDITS CURRENT? YES NO DATE GRADUATED: RULE 20 CERTIFIED? YES NO DATE ADMITTED TO PRACTICE IN OHIO: RULE 20 SEMINAR ATTENDED: DATE ANNUAL DBA CRIMINAL LAW CERTIFICATION SEMINAR ATTENDED: RULE 20 CERTIFICATION DATE: APPLICATION FOR APPOINTED COUNSEL PROGRAM: FELONY 3-5 UPGRADE TO FELONY 1-5 PRO BONO/VOLUNTEER COUNSEL: I am willing to accept If you are unavailable, can someone accept appointments for you? RULE 20 APPEALS Pro Bono cases annually. YES NO If yes, who? REQUEST FOR UPGRADE If you are requesting an upgrade, please complete the attached experience worksheet and provide at least three or more cases as support for your request. I WOULD ALSO LIKE TO BE CONSIDERED FOR UNCLASSIFIED (NON-CAPITAL) CASE APPOINTMENTS. OTHER RELEVANT EXPERIENCE OR TRAINING: I have reviewed the Qualifications, Regulations and Standards of the Ohio Public Defender's Commission and certify that I meet the mimimum requirements to be appointed to represent indigent defendants. I am willing to serve as counsel in accordance with and subject to all applicable rules, guidelines, and statutes that govern this process. I agree to notify the Court, in writing, of any changes in personal or professional status that would affect my ability or qualification to serve as appointed counsel for indigent defendants. I understand that Appointed Counsel Payment Packages must be submitted within (30) thirty days from filing of the termination entry and that each package must include an executed affidavit of indigency. *Attorney Signature *indicates required fields Date Mail Application to: Appointed Counsel Coordinator Montgomery County Common Pleas Court 41 N. Perry Street, Room 038 Dayton, Ohio 45422 (OR) Fax to: 937-824-7966 Revised 2/09 American LegalNet, Inc. www.FormsWorkflow.com Montgomery County Common Pleas Court General Division 41 N. Perry St. P.O. Box 972 Dayton, OH 45422 APPLICATION FOR APPOINTED COUNSEL AND PRO BONO PROGRAMS EXPERIENCE WORKSHEET Use this worksheet for cases that you have handled that should be considered by the court in evaluating your request for an upgrade. DISPOSITON Case # Court Case Name Charge(s) Felony Level Plea Jury Verdict Case History (motions, hearings, decisions, disposition) American LegalNet, Inc. www.FormsWorkflow.com