APPLICATION TO BE PLACED ON PUBLIC APPOINTMENT LIST BRAZOS COUNTY, TEXAS Name Name of Law Firm Bar Card No. Date of Birth Physical Office Address Street Suite No. City Zip + 4 Office Mailing Address P.O. Box City Office Telephone No. Mobile Telephone No. E-Mail Address Zip + 4 ( ( ) ) - Office FAX No. Pager No. ( ( ) ) - Mark each public appointment list on which you want to be placed: Misdemeanor List Other Felony List 3g/Enhanced Felony List Capital Felony List Appellate List Please answer the following questions by marking the box in the appropriate column. (Attach additional sheet to provide any necessary explanation or request waiver) Have you been the recipient of any public disciplinary action by the State Bar of Texas or any other attorney licensing authority of any state or the United States within the last five (5) years? Have you been convicted of any felony offense or of any misdemeanor involving moral turpitude within the last ten (10) years? Are you now delinquent in the payment of any obligations to the State Bar of Texas, or to any taxing authority, including Brazos County, the State of Texas, and the United States? Are you now delinquent in the payment of any child support obligations? YES NO Are your FAX machine and telephone capable of receiving information 24 hours per day? Please answer the following questions. (Attach additional sheet to provide any necessary explanation or request waiver) How many years have you actively practiced criminal law? How many criminal jury trials have you tried to a verdict as lead counsel? How many hours of continuing legal education instruction have you attended in the area of criminal law before making this application? Are you currently certified in criminal law by the Texas Board of Legal Specialization? If applying for Appellate List, in how many criminal cases have you acted as counsel on appeal? I, the undersigned attorney, declare that the statements made in this application are true and correct. I further declare that I have read the Brazos County Indigent Defense Plan and will comply with all requirements of that plan. Attorney’s Signature: ________________________________________________ Date: _____________ SWORN TO AND SUBSCRIBED BEFORE ME, the undersigned authority, by the above stated person on this _____day of _____________________, 20______. (NOTARY’S SEAL OF OFFICE) NOTARY’S SIGNATURE: ________________________________ Revised August 11, 2006 APPENDIX A American LegalNet, Inc. www.FormsWorkflow.com