UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF TEXAS DALLAS DIVISION CRIMINAL JUSTICE ACT VOLUNTARY PANEL QUESTIONNAIRE AND APPLICATION Please return original and three copies to: Attn: CJA Panel Attorney Program United States District Court 1100 Commerce Street, Rm. 1452 Dallas, Texas 75242 A. General Information 1. Name: _____________________________________________________________________ (Last) (First) (Middle) 2. Office Address: ______________________________________________________________ (Firm Name) ______________________________________________________________ (Street) 3. Telephone Numbers: _______________________ (City) (State) (ZIP) _______________________ (Office) (Home) ______________________ ______________________ (FAX) (Pager) ______________________ _______________________ (Mobile) (Internet E-mail) 4. What is the best way to contact you in an emergency? ________________________________ ______________________________________________________________________________ 5. Bar Number: ____________________________________________ 6. Date Admitted to Texas Bar: ________________________________ 7. Date Admitted to NDTX: ___________________________________ 8. What other Federal Districts have you been admitted to: ______________________________ ______________________________________________________________________________ 9. Law School from which you received your JD:_____________________________________ American LegalNet, Inc. www.FormsWorkflow.com 10. Professional Affiliations: ‘ DBA ‘ JLT ‘ MABA ‘ Dallas Criminal Defense Lawyers ‘ AABA ‘ Other: __________________ ‘ Texas Criminal Defense Lawyers ‘ NACDL B. Trial & Legal Experience 11. Indicate your Criminal Trial experience by providing approximate totals in the following categories: Federal Court State Court Jury Trials _______________________ _______________________ Bench Trials _______________________ _______________________ Pleas & Sentences _______________________ _______________________ Appeals _______________________ _______________________ Other Court Hearings _______________________ _______________________ 12. Indicate your Civil Trial experience by providing approximate totals in the following categories: Federal Court State Court Jury Trials _______________________ _______________________ Bench Trials _______________________ _______________________ Other Court Hearings _______________________ _______________________ Depositions _______________________ _______________________ 13. Indicate any other legal experience which qualifies you for membership on the panel (including experience in a prosecutor’s or public defender’s office or as a judicial law clerk and areas in which you are a Board Certified Specialist): ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ CONTINUED ON NEXT PAGE. American LegalNet, Inc. www.FormsWorkflow.com 14. List the names and phone numbers of three judges and three lawyers who know of your ability as a trial attorney: Judges: Attorneys: ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ ________________________________ C. Miscellaneous Information 15. Have you ever been disciplined by, or are you the subject of a pending disciplinary complaint before any Bar Association or Court? ‘ Yes ‘ No If “Yes” please describe the facts concerning the discipline or the pending disciplinary complaint: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ 16. Are you fluent in any foreign language(s)? ‘ Yes ‘ No If “Yes” please list: _________________________________________________________________ Are you willing to take additional appointments based on your foreign language proficiency? ‘ Yes ‘ No If “Yes” how many per year? _______________________ 17. How many court appointments would you like to receive annually?________________________ I HEREBY CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. ______________________________________ Signature _______________________________ Date American LegalNet, Inc. www.FormsWorkflow.com