APPLICATION FOR MEMBERSHIP ON A CRIMINAL JUSTICE ACT PANEL FOR THE UNITED STATES DISTRICT COURT, NORTHERN DISTRICT OF OHIO Name: Bar ID No: Desired Panel: Office Address: SSN: Email Address: Phone No: Fax No: The Court expects attorneys to file documents electronically pursuant to its Electronic Filing Policies and Procedures Manual. Are you currently registered with this Court to file electronically? (If no, please submit a completed Electronic Filing Registration form with this application.) Yes No The Court requires annual attendance at a Federal Criminal Practice seminar. Your application will not be considered unless you provide proof of attendance at such a program within the last 12 months (see question VIII). I. Bar Admission & Education: A. Court Admission: List all courts in which you have been admitted to practice, with dates of admission, whether you are a member in good standing, and lapses if any such membership lapsed. Court + B. Admission Date Current Status Comment State whether your license or right to practice in or before any court, agency or other tribunal has ever been suspended, revoked, or denied, and if so, explain fully the facts and circumstances. C. Education: List each college and law school you have attended, including dates of attendance, degrees received, and dates degrees were granted. College/Law School + - Dates of Attendance Degree Date Degree Conferred American LegalNet, Inc. www.FormsWorkFlow.com II. Employment History: A. Legal Career: List by year, in reverse chronological order, all law-related employment you have held since graduating from law school. Please provide the name and telephone number of at least one supervisor, co-worker or partner familiar with your work during the time you held each position. Dates + B. Firm/Institution Name Telephone Number Litigation History: List three criminal cases which you personally handled and provide the following information as to each case: (1) (2) (3) (4) (5) (6) the case caption; the name of the party or parties whom you represented; the date of representation; the nature of your participation in the litigation and the final disposition of the case; the name of the court and the name of the judge or judges before whom the case was litigated; and the individual names, addresses, and telephone numbers of your co-counsel and of principal counsel for each of the other parties. Case One: Case Two: Case Three: American LegalNet, Inc. www.FormsWorkFlow.com III. Criminal Case Experience: A. Rate your experience in and knowledge of: The Federal Rules of Criminal Procedure: The Federal Rules of Evidence: U.S. Sentencing Guidelines: B. C. D. E. Approximate number of felony cases tried to verdict in federal court as primary defense attorney during the last five years: Approximate number of felony cases tried to verdict in federal court as secondary defense attorney during the last five years: Approximate number of felony cases tried to verdict in state court as primary defense attorney during the last five years: Approximate number of felony cases tried to verdict in state court as secondary defense attorney during the last five years: Approximate number of federal sentencing hearings under the Federal Sentencing Guidelines: Approximate percentage of practice devoted to criminal defense work in the last five years: Approximate number of misdemeanor cases tried to verdict as primary counsel in the last five years: F. G. H. IV. Appellate Experience: For each category, please provide the approximate number of criminal case appeals in which you wrote the brief and argued the case during the time periods indicated: A. Any state court of appeals: Past 0-5 Years: B. Any state supreme court: Past 0-5 Years: C. Past 6-10 Years: More than 10 Years Ago: Past 6-10 Years: More than 10 Years Ago: Any federal circuit court of appeals: Past 0-5 Years: Past 6-10 Years: More than 10 Years Ago: D. The Supreme Court of the United States: Past 0-5 Years: Past 6-10 Years: More than 10 Years Ago: American LegalNet, Inc. www.FormsWorkFlow.com V. Indigent Representation Experience: A. Are you currently a member of an assigned counsel list in any court or do you regularly receive assignments to represent indigent persons in felony cases? If so, please note courts and length of service: Yes No B. Approximate number of felony cases received by appointment in any state court during the last five years: Two years: C. Approximate number of felony cases received by appointment in any federal court during the last five years: Two years: VI. Capital Case Experience: Please note the approximate number of capital cases that you have handled and indicate whether you were primary or secondary counsel: A. State Court Primary Counsel B. State Court (to jury verdict) Primary Counsel C. Direct Appeal in state court Primary Counsel D. Habeas corpus/collateral attack in state court Primary Counsel E. Federal Court Primary Counsel F. Federal court trial (to jury verdict) Primary Counsel G. Direct appeal in federal court American LegalNet, Inc. www.FormsWorkFlow.com Secondary Counsel Secondary Counsel Secondary Counsel Secondary Counsel Secondary Counsel Secondary Counsel Primary Counsel H. Habeas corpus/collateral attack in federal court Primary Counsel I. The United States Supreme Court Primary Counsel VII. Please check the types of federal assignments you are willing to accept: Felony trial: Habeas corpus (non-capital) in district court: Capital cases at trial: VIII. Secondary Counsel Secondary Counsel Secondary Counsel Felony appeal: Habeas corpus (non-capital) in court of appeals: Capital cases on appeal: Please note date(s) of completion of continuing legal education (CLE) seminar(s) on federal criminal defense practice: IX. Disciplinary Proceedings: Have you ever been disciplined, censured, sanctioned, held in contempt, or cited for a breach of ethics or for unprofessional conduct by any court, administrative agency, bar association, or other professional group? Yes No If so, please briefly describe in full the circumstances: X. Provide the names and current phone numbers for three judges with whom you are not and have not been associated in the practice of law or in business before whom you have appeared recently in matters which would afford them an opportunity to observe your professional conduct and ability in criminal matters. Judicial Officer Contact Information American LegalNet, Inc. www.FormsWorkFlow.com XI. Provide the names an