COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. APPLICATION FOR INCLUSION ON CJA PANEL : NAME: LAW FIRM AND BUSINESS ADDRESS: HOME ADDRESS: Plaintiff(s) -against- PHONE: Calendar No. : JUDICIAL SUBPOENA BUSINESS : OTHER: EMAIL ADDRESS (to be used only for CJA mailings) : SOCIAL : SECURITY NUMBER OR EMPLOYER I.D. NUMBER: : Institution(s) conferring legal degree(s) and date(s) received: Defendant(s) : ...................................................... Date(s) of admission to state court of last resort and name of state(s) (REQUIRED): THE PEOPLE OF THE STATE OF NEW YORK Date of admission to the U.S. District Court of the Eastern District of Tennessee (REQUIRED): TO Admission to other federal courts: Name of Court Date of Admission GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Has any disciplinary action for attorney misconduct been abjudicated against you by any court, bar association, or located at County of regulatory agency? the Yes day of No in room , on , 20 , at o'clock in the noon, and at any recessed If yes, give date, to testify tribunal, the date and disposition of the case. the name of the and give evidence as a witness in this action on the part of the or adjourned Has any professional to comply with this subpoenamade against you? a contempt Yes Your failure liability claim or suit ever been is punishable as If yes, provide the date and disposition of the case and nature of the claim.penalty of the party on whose behalf this subpoena was issued for a maximum of court andNo make you liable to will $50 and all damages sustained as a result of your failure to comply. Witness, how many federal criminal cases have you provided representation asof the Justices ofin the last five , one counsel of record the In approximately Honorable Court in County, day of , 20 years? In approximately how many state or federal criminal and civil trials have you participated as counsel? Non-Jury: _________________ Jury Trials: __________________ (Attorney must sign above and type name below) In what Continuing Legal Education have you participated in the past three years that would be pertinent to your representation of clients under the CJA? Attorney(s) for Do you have any second language capabilities or other skills that might enable you to represent clients with special needs? Office and P.O. Address Yes No If yes, please describe: Date: Signature: Telephone No.: Applicant Facsimile No.: Submit completed form to the United E-Mail Address: States District Court Clerk. Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com