This Application requests your admission to a specialized panel of attorneys willing to serve as counsel in non-capital habeas corpus cases. By submitting this application, you are indicating your willingness to represent prisoners who have filed in propria persona applications for federal review. If appointed, you will be compensated at the hourly rate applicable to non-capital representations. NON-CAPITAL HABEAS CORPUS 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). American LegalNet, Inc. www.FormsWorkFlow.com 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. 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. 2 American LegalNet, Inc. www.FormsWorkFlow.com C. If you are in a law firm, do you have an immediate supervisor. Yes ____ No ____ If yes, who is your supervisor? __________________________________________ Will your supervisor be involved in this case? If so, in what capacity: V. 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 ____ VI. Do you have malpractice insurance? Yes ____ No ____ If "No", are you willing to accept appointment under these circumstances? Yes ____ VII. 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. 3 American LegalNet, Inc. www.FormsWorkFlow.com VIII. Are you enrolled for electronic filing and equipped to participate? Yes ____ No ____ I hereby certify that the above information is true and correct. Date: _______________ s/__________________________________ Attorney Return promptly by conventional mail, fax or email to: Susan M. Otto Federal Public Defender Suite 109 Old Post Office Bldg. 215 Dean A. McGee Avenue Oklahoma City, Oklahoma 73102 Susan_Otto@fd.org 405-609-5932 (fax) PRINT and RESET FORM 4 American LegalNet, Inc. www.FormsWorkFlow.com