STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS FAMILY COURT APPLICATION FOR APPOINTMENT AS FAMILY COURT JUSTICE OF THE PEACE NEW RENEWAL To the Honorable Haiganush R. Bedrosian, Chief Judge of the Family Court: I, , residing at hereby request appointment to the office of Family Court Justice of the Peace. In support of this application, I hereby certify under oath that: 1. I am an attorney in good standing admitted to practice before the Courts of the State of Rhode Island, having first been admitted on . I am a Justice of the Peace duly commissioned by the Governor of the State of Rhode Island, my current term set to expire on . Copies of a Certificate of Good Standing from the Rhode Island Supreme Court and my Commission as a Justice of the Peace commissioned by the Governor of the State of Rhode Island are attached. do 2. 3. Signature of Applicant Rhode Island Bar Number: State of _______________________ County of _____________________ On this ________ day of ________________, 20____, before me, the undersigned notary public, personally appeared ____________________________________ personally known to the notary or proved to the notary through satisfactory evidence of identification, which was _____________________________________________, to be the person who signed the preceding or attached document in my presence, and who swore or affirmed to the notary that the contents of the document are truthful to the best of his or her knowledge. Notary Public: ____________________________________ My commission expires: ____________________________ Notary identification number: ________________________ FC-37 (revised April 2013) American LegalNet, Inc. www.FormsWorkFlow.com