CRIMINAL JUSTICE ACT PANEL APPLICATION WESTERN DISTRICT OF OKLAHOMA I. Identification: Name: __________________________________________________________________ Last First Middle Initial Office address, including name of firm: Office Telephone: ___________________________ Office Facsimile: ___________________ Cellular Phone: _________________________________________________________________ E-mail Address: ________________________________________________________________ Social Security Number __________ - _____ - __________ II. Legal Education: What law degree(s) have you received? Specify the law school and the date the degree was received. (E.g., J.D., OCU, 1975). III. A. Law Licenses: Identify the states in which you are currently admitted to practice law, including the date of admission. (E.g., Oklahoma, 1987). B. Identify all federal courts in which you are currently admitted to practice, including the date of admission. American LegalNet, Inc. www.FormsWorkFlow.com IV. Legal Experience: A. Describe the nature of your present practice. Include the dates of such practice and the names of the attorneys with whom you practice. ``. B Describe the nature of your past practice if different than in subpart "A". Include the addresses and dates of your past practice and identify the attorneys with whom you practiced. C. Indicate by number your criminal trial experience. (Use approximations if necessary): Trials in Federal Courts: Trials in State Courts: Guilty Pleas & Sentences in Federal Courts: Guilty Pleas & Sentences in State Courts: ____ ____ ____ ____ D. Indicate by number your civil trial experience. (Use approximations if necessary): Trials in Federal Courts: Trials in State Courts: ____ ____ E. For your last five criminal trials, provide: (1) the court and trial judge; (2) case name and number; (3) date(s) of trial; and (4) name, address and telephone number of opposing counsel. 2 American LegalNet, Inc. www.FormsWorkFlow.com 1. Do you consent to contact by the CJA Committee to the judge and your opposing counsel regarding your representation in these cases? Yes No F. Identify the federal district judges and magistrate judges before whom you have tried a case or cases. (Indicate criminal cases with the marking "CR"). G. If you have argued case(s) before a federal appellate court, provide the citation(s) of the opinion(s). If unpublished, provide the case number(s) and briefly describe the case(s). H. Describe any specific experience, training, or interest you have in criminal law. V. If you are chosen as a member of the Criminal Justice Act Panel, will you allow attorneys seeking membership in the Panel to observe you in court and will you be able to give guidance to those attorneys? Yes No VI. Do you understand that your application is not considered confidential and that the appointees may be removed from Panel membership without cause or notice? Yes No 3 American LegalNet, Inc. www.FormsWorkFlow.com VII. Do you understand that the Criminal Justice Act will not provide indemnification for any claims arising as a result of your representation of a CJA client? Yes No VIII. Do you have malpractice insurance? Yes No If "No", are you willing to accept appointment under these circumstances? Yes IX. No With respect to your legal practice, has a final adjudication or other finding ever been made by an Bar Association, Ethics Committee, Court, or other judicial or quasi-judicial body concerning your ethics or any other disciplinary matter? Yes No If your response was in the affirmative, please explain fully and completely each such finding. X. Are you enrolled for electronic filing and equipped to participate? Yes No XI. Provide the name, address, and telephone number of at least three references with substantial knowledge regarding your credentials for panel membership: 4 American LegalNet, Inc. www.FormsWorkFlow.com XII. State with specificity all training and experience that you have had with the federal sentencing guidelines: XIII. State any other information that you want us to know, including but not limited to any lawrelated publications or honors: I hereby certify that the above information is true and correct. Date: _______________ s/__________________________________ Attorney Return promptly by conventional mail, fax or email to: Kim Kakish CJA Panel Administrator Suite 109 Old Post Office Bldg. 215 Dean A. McGee Avenue Oklahoma City, Oklahoma 73102 Kim_Kakish@fd.org 5 American LegalNet, Inc. www.FormsWorkFlow.com