Board of Law Examiners Appointed by the Supreme Court of Texas SUPPLEMENTAL INVESTIGATION Carefully follow these instructions and complete these forms, typing or printing your answers. Use blue or black ink if you choose to print. Keep a copy of your Supplemental Investigation for future reference, as you may be charged for any copies you request from the Board’s file. Absolutely no alterations may be made to the text or wording of this Supplemental Investigation. If alterations are found, the Supplemental Investigation will be rejected and your fees forfeited. Your Supplemental Investigation will not be considered filed and may be returned to you if it is incomplete. Examples of incompleteness include, but are not limited to, the following: a. failure to provide any information required, including names, complete addresses, telephone numbers, and/or zip/postal codes; b. failure to answer any question or subquestion; c. failure to provide a complete and separate Continuation Form, Civil Litigation Form and Criminal History Form for each response requiring one; d. failure to send in the required fees; e. any indecipherable answers; f. any signature notarized more than 90 days before the date received by BLE; g. alteration of any language of the Supplemental Investigation, Affidavit, Authorization and Release, or other required form; or h. failure to sign any document requiring your signature and/or failure to have your signatures notarized where required. Before you file your Supplemental Investigation, verify that you have fully responded to all items, questions, and statements, leaving no blanks and attaching all required Continuation Forms, Civil Litigation Forms, Criminal History Forms, and an original signed and notarized Authorization and Release Form. If the item or question is inapplicable, write “N/A.” Incomplete Supplemental Investigations may be rejected. If you have not enclosed required documentation that you must obtain from third parties (e.g., court records, etc.), explain on a Continuation Form as required in item 20. You must make a good faith effort to provide these items within 30 days of our receipt of your Supplemental Investigation. Your failure to meet this deadline may cause your Supplemental Investigation to be returned to you as not being properly filed. This 30-day grace period DOES NOT APPLY to the Continuation, Criminal History Forms, and Civil Litigation Forms that must be filed with your Supplemental Investigation, if applicable. 1. Filing Fees: Make your check, money order, or bank cashier’s check payable to the BOARD OF LAW EXAMINERS (NOT the State Bar of Texas) in the amount of $190.00. Do not postdate your check. A Supplemental Investigation is not considered filed until all associated fees are received in the BLE office. If your personal check for fees is returned for insufficient funds or is otherwise dishonored by your bank, you may be assessed a returned check charge. All fees due after that time must be paid by bank cashier’s check or money order. There is no refund of fees if you withdraw your Supplemental Investigation or do not meet all requirements for admission. 2. Filing of Supplemental Investigation: Mail or deliver your Supplemental Investigation and all attachments and required fees to the Board as follows: MAILING ADDRESS: Board of Law Examiners P.O. Box 13486 Austin, TX 78711-3486 DELIVERY ADDRESS: Board of Law Examiners 205 West 14th Street, 5th Floor Austin, Texas 78701 i 3. Period of Time Covered by the Supplemental Investigation: You must contact the Board office to obtain the date to enter at the top of page 1. 4. Authorization/Release Form: Provide two (2) ORIGINAL, SIGNED, and NOTARIZED Authorization/Release forms. Do not send copies. Blank forms are attached for your use. These forms must be filed simultaneously with your Supplemental Investigation. 5. Expunged and Sealed Offenses: Matters expunged pursuant to Texas Code of Criminal Procedure Art. 55.02, or pursuant to another State’s statute with the same force and effect, need not be disclosed. While expunged or sealed offenses, arrests, tickets, or citations need not be disclosed, it is your responsibility to ensure the offense, arrest, ticket, or citation has, in fact, been expunged or sealed. It is recommended that you obtain a copy of the Court Order expunging or sealing the record in question. Failure to reveal an offense, arrest, ticket, or citation that is not in fact expunged or sealed, raises questions related to truthfulness in addition to questions regarding the offense itself. Note that orders of nondisclosure pursuant to Govt. Code §411.081 are not orders of expunction. 6. Orders of Non-Disclosure: Pursuant to the Govt. Code Sec. 552.142 (b), if you have criminal matters that are the subject of an order of non-disclosure you are not required to reveal those criminal matters on this form. However, a criminal matter that is the subject of an order of non-disclosure may become a character and fitness issue. Pursuant to other sections of the Government Code 411.081(d), 411.081(i)(5), 411.083(b), 411.084(a), 411.087(a), and 411.100, the Texas Board of Law Examiners is entitled to access criminal history record information that is the subject of an order of nondisclosure. Therefore, if the Board discovers a criminal matter that is the subject of an order of non-disclosure, even if you properly did not reveal that matter, the Board may ask you to provide information about that criminal matter. 7. Civil Litigation Forms: One Civil Litigation Form is attached to your Supplemental Investigation; make additional copies as needed. Use this Form as directed in the Supplemental Investigation. If applicable, these forms must be filed simultaneously with your Supplemental Investigation. 8. Criminal History Forms: One Criminal History Form is attached to your Supplemental Investigation; make additional copies as needed. Use this form as directed in the Supplemental Investigation. If applicable, these forms must be filed simultaneously with your Supplemental Investigation. 9. Continuation Forms: One Continuation Form is attached to your Supplemental Investigation at page 14; make additional copies as needed. Analyze the Supplemental Investigation carefully to determine how many forms you will need before you mark on the one copy provided. Use this form as directed in various questions in the Supplemental Investigation to provide an explanation for “yes” answers and/or to continue your answers if additional space is required to complete responses to any question or statement for which a specifically designated form is not provided. Respond to only one question or statement on each Continuation Form. Do not forget the requirement in item 20 to list on a Continuation Form all documentation not provided with your Supplemental Investigation. All applicable Continuation Forms must be filed simultaneously with your Supplemental Investigation. 10. Employment History:(a) If an employer is no longer in business, you should enter the phrase “no longer in business” on the line for the supervisor’s name, instead of listing the name of your supervisor. (b) If your immediate supervisor is no longer employed by the employer, you have a choice: either list the name of another supervisor still employed by the employer who will be able to respond to an inquiry from the Board staff as to your honesty, etc., or list the current address of your former supervisor, wherever that person is now, or if neither is a viable option, state “personnel department.” (c) If you cannot locate any documentation that indicates the exact dates you were employed, list the approximate dates, but indicate that they are approximate. (d) If you were employed in a non-paid, intern-type position, you should list such employment situations. Board staff will elicit responses as to your honesty, etc., so the fact that you were not paid is not important. ii 11. FBI Fingerprint Card: A fingerprint check with the Federal Bureau of Investigation is mandatory. The staff of the Board of Law Examiners cannot complete the investigation of your Application without the results of your FBI fingerprint check. Current information on the fingerprinting requirement is available on the Board’s website, www.ble.state.tx.us, under the Fingerprinting link for Supplemental Investigations. 12. Court Records: You must provide legible copies of all requested court records as specified on the Supplemental Investigation. 13. Full Disclosure: It is imperative that you honestly and fully answer all questions, regardless of whether you believe the information requested is relevant. Your responses on your Supplemental Investigation are evaluated as evidence of your candor and honesty. An honest “yes” answer to a question on your Supplemental Investigation is not definitive as to the Board’s assessment of your present moral character and fitness, but a dishonest “no” answer is evidence of a lack of candor and honesty, which may be definitive on the character and fitness issue. 14. Obligation to Update: You are obligated to immediately update the Board of any matters required by the language contained in the Affidavit section on pages 10-11. 15. LSAC Account Number: You must provide your Law School Admission Council’s (LSAC) Account Number. The link for the LSAC account number lookup is http://lsaclookup.lsac.org/lookup.aspx. If you have interacted with LSAC in any way, you have an LSAC account number. If you do not have an LSAC account number, you need to create an account by going to http://lsaclookup.lsac.org/lookup.aspx. Your Supplemental Investigation will be returned if you leave the LSAC account number field blank. Only Admission Without Examination applicants are allowed to leave the LSAC account number field blank. iii Board of Law Examiners Appointed by the Supreme Court of Texas Mailing Address: P. O. Box 13486, Austin TX 78711-3486 Physical Address: 205 West 14th Street, 5th Floor, Austin TX 78701 SUPPLEMENTAL INVESTIGATION The period of time to be covered in your responses on this form should be from ______________________ to the present. You must contact the Board office to obtain the date to enter here. [ ] Mr. NAME: [ ] Ms. __________________________________________________________________________________ Last First Middle Maiden ______________________ Date of Birth MAILING ADDRESS: _______________________ Social Security No.* _________________________ Driver’s License/I.D. No. __________________ Issuing State (All correspondence will be mailed to this address.) _________________________________________ ______________________ Street Address/P.O. Box Apt. No City Home Phone: ____________________ ________________ State _____________ Zip Code Work Phone: ____________________ Cell Phone: ____________________ Email address: _____________________________________________________________________________________ NAME & TELEPHONE NUMBER OF A PERSON WHO CAN CONTACT YOU: ______________________________ Name ______________________________ Relationship ______________________________ Telephone Number LAW SCHOOL ADMISSION COUNCIL (LSAC) Account Number: __________________________ (LSAC Account Number: You must provide your Law School Admission Council’s (LSAC) Account Number. The link for the LSAC account number lookup is http://lsaclookup.lsac.org/lookup.aspx. If you have interacted with LSAC in any way, you have an LSAC account number. If you do not have an LSAC account number, you need to create an account by going to http://lsaclookup.lsac.org/lookup.aspx. Your Supplemental Investigation will be returned if you leave the LSAC account number field blank. Only Admission Without Examination applicants are allowed to leave the LSAC account number field blank.) 1. Within the period covered, have you ever been known by any other name or surname? . . . . . . . .__________ (yes or no) If you answered “YES”, give the following information: Other Complete Name Explanation of change __________________________ ______________________________ _______________________________ __________________________ 2. Duration of Use ______________________________ _______________________________ List all colleges or universities you have attended within the period covered, starting with the institution most recently attended and working backward. Use a Continuation Form if you have attended more than one institution. _____________________________________________________________________________________________ Institution Dates of Attendance Degree _____________________________________________________________________________________________ Street Address City State/County Zip/Postal Code _______ Check here if a Continuation Form is attached. * The provision of your social security number is voluntary, pursuant to Sec. 7, Privacy Act of 1974. However, when this data is provided, the Board will use it in its investigation and verification, to minimize errors of identity, which might introduce problems and delays into the certification and licensure process. The Board appreciates your furnishing this information on a voluntary basis. BLE-10 SI 7-2011.doc 1 3. Within the period covered, have you ever been disciplined in any way for any matter by any college, university, law school or other institution of higher learning, or by any professor, administrator, employee or entity representing any college, university, law school or other institution of higher learning, or have you been allowed to withdraw from such an institution to avoid such discipline, whether or not the record of such action was retained in your file? (Discipline includes, without limitation, a letter or other written notice of reprimand or warning, suspension, expulsion, adjustment of grade, assignment of community service, any form of probation, or any other adverse action). (Entity includes, without limitation, residential facilities or other facilities owned or managed by a college, university, law school, or other institution of higher learning.) _________ yes or no If you answered “YES” to Question 3, provide a narrative explanation on a Continuation Form, and provide copies of all relevant documents. _______ Check here if a Continuation Form is attached. 4. Within the time covered, have you been terminated, suspended, disciplined, or permitted to resign in lieu of termination, suspension, or discipline, from any job or employment? _________ yes or no If you answered “YES” to Question 4, provide a narrative explanation on a Continuation Form of the circumstances surrounding each such occurrence. _______ Check here if a Continuation Form is attached. 5. Beginning with your current or most recent employment, list all employment (including self-employment, externships, paid and unpaid internships, clerkships, part-time employment, and temporary employment) you have held for any period of time within the period covered. Use the attached Employment Form if additional space is needed. Use the enclosed Employment Form (on page 15) if you list more than three (3) employers. Refer to item 13 of the General Instructions for additional guidance in providing employment data. (a) Name of Employer: ____________________________________________________________________________ Current address: _______________________________________________________________________________ Street/P.O. Box City State/Country Telephone number: ______________________________ Zip/Postal Code Dates employed: _____________________________ Area Code From (mm/dd/yy) To (mm/dd/yy) Position Held: __________________________________ Name of Supervisor: _________________________ Reason for leaving: ____________________________________________________________________________ If this employment is/was self-employment, or if the employer is now out of business, provide the name, current mailing address and telephone number of a verifying reference. Name: ________________________________________________________________________________________ Address: _______________________________________________________________________________________ Street/P.O. Box City State/Country Zip/Postal Code Daytime telephone number: ________________________________________________________________________ Area Code BLE-10 SI 7-2011.doc 2 (b) Name of Employer: ___________________________________________________________________________ Current address: _______________________________________________________________________________ Street/P.O. Box City State/Country Telephone number: ______________________________ Zip/Postal Code Dates employed: _____________________________ Area Code From (mm/dd/yy) To (mm/dd/yy) Position Held: __________________________________ Name of Supervisor: _________________________ Reason for leaving: ____________________________________________________________________________ If this employment is/was self-employment, or if the employer is now out of business, provide the name, current mailing address and telephone number of a verifying reference. Name: ________________________________________________________________________________________ Address: _______________________________________________________________________________________ Street/P.O. Box City State/Country Zip/Postal Code Daytime telephone number: ________________________________________________________________________ Area Code (c) Name of Employer: ___________________________________________________________________________ Current address: _______________________________________________________________________________ Street/P.O. Box City State/Country Telephone number: ______________________________ Zip/Postal Code Dates employed: _____________________________ Area Code From (mm/dd/yy) To (mm/dd/yy) Position Held: __________________________________ Name of Supervisor: _________________________ Reason for leaving: ____________________________________________________________________________ If this employment is/was self-employment, or if the employer is now out of business, provide the name, current mailing address and telephone number of a verifying reference. Name: ________________________________________________________________________________________ Address: _______________________________________________________________________________________ Street/P.O. Box City State/Country Zip/Postal Code Daytime telephone number: ________________________________________________________________________ Area Code _______ Check here if a Employment Form and/or a Continuation Form is attached relating to Question 5. BLE-10 SI 7-2011.doc 3 6. Within the period covered, list each city, including any in Texas, and state, and/or foreign country where you have resided, worked, or attended school for three (3) consecutive months or longer. Use a Continuation Form if necessary. Do not answer “N/A” for this item. From (mm/yy) To (mm/yy) City, State (and Foreign County, if applicable) ___________________ ___________________ _______________________________________________ ___________________ ___________________ _______________________________________________ ___________________ ___________________ _______________________________________________ ___________________ ___________________ _______________________________________________ _______ Check here if a Continuation Form is attached. 7. A person who is recommended for licensure to practice law in the State of Texas must execute an oath of office upon licensure and must swear, among other things, that he/she “...will support the Constitution of the United States, and of this State...” Will you execute the required oath of office if you are recommended for licensure in the State of Texas? _________ yes or no If you answered “NO” to Question 7, explain your answer on a Continuation Form. _______ Check here if a Continuation Form is attached. 8. Within the period covered, have you served in the Armed Forces of the United States of America? _________ yes or no If you answered “YES” to Question 8, attach a Continuation Form with a summary of your current or past service in the Active, Reserve, or National Guard forces. You must include a detailed explanation of any administrative or disciplinary proceedings brought against you in the Armed Forces. In addition, if you have completed any active duty service in the Armed Forces, provide a copy of your DD Form 214 (Certificate of Release or Discharge From Active Duty) that indicates your character of service. (If you do not have a copy, you may obtain one by writing to National Personnel Records Center, Military Personnel Records, 9700 Page Blvd., St. Louis, MO 63132, telephone #: (314) 538-4229). For completed service with the Reserve or National Guard forces, furnish a copy of your discharge document. _______ Check here if a Continuation Form is attached. 9.(a) Within the period covered, have you been a party to any civil suit or proceeding (including but not limited to any matters in which you were the subject of a proceeding for commitment based on incompetency, mental health, or substance abuse)? If you answered “YES” to Question 9(a), attach a separate Civil Litigation Form for each matter. On each Form, indicate in the “Disposition” Section whether the matter has been concluded or is still pending. If you are, or were, a plaintiff, you must complete the Form, but you are not required to attach any documentation. BLE-10 SI 7-2011.doc 4 _________ yes or no If you were a defendant in a matter that has been concluded, attach a legible copy of the docket sheet. If a judgment was rendered against you, attach a legible copy of the judgment and proof of satisfaction, if applicable. Provide an explanation if the judgment has not been satisfied. If the matter resulted in a settlement, provide a summary of the terms as they relate to you and a statement as to whether you adhered to same. If you are a defendant in a matter that is pending, attach a legible copy of the docket sheet and a legible copy of the most recent petition/complaint. _______ Check here if a Continuation Form is attached. (b) Within the period covered, have you ever been convicted of an offense, placed on probation, or granted deferred adjudication or any type of pretrial diversion? You must report any such offenses involving alcohol or drugs. You must report any failure to appear conviction resulting from any offense. You must report any conviction for failure to maintain financial responsibility (legally required auto insurance). You may exclude only Class C misdemeanor traffic violations. _________ yes or no (c) Within the period covered, have you been arrested, cited or ticketed for, or charged with any violation of the law? You must report any such offenses involving alcohol or drugs. You must report any failure to appear charge or warrant resulting from any such offense. You must report any failure to maintain financial responsibility (legally required auto insurance) arrest, citation, ticket, or charge. You may exclude only Class C misdemeanor traffic violations. _________ yes or no If you answered “YES” to Question 9(b) or (c), attach a separate Criminal History Form for each arrest, charge, citation, or ticket. Arrest/offense reports. If any of the offenses you describe resulted from an arrest (as opposed to a citation or a ticket) that occurred within five years of the date you sign this Supplemental Investigation Form, you are responsible for either providing legible copies of the arrest/offense reports for such offenses, or providing proof that you made a written request for such reports. You are not required to provide copies of any citations or tickets. Court records. If any of the offenses you describe, whether they resulted from an arrest, citation or ticket, occurred within five years of the date you sign this Supplemental Investigation Form, you are responsible for either providing legible copies of all court records for all such offenses, or providing proof that you made a written request for such court records. It is very important that you make your written requests to the correct agency or court. _______ Check here if a Criminal History Form is attached. NOTE: If you have ever been convicted of a felony, or have been placed on probation for a felony, with or without an adjudication of guilt, read Rule IV(d) carefully. You may be prohibited from filing this form. NOTE: Expunged and Sealed Offenses: Matters expunged pursuant to Texas Code of Criminal Procedure Art. 55.02, or pursuant to another State’s statute with the same force and effect, need not be disclosed. While expunged or sealed offenses, arrests, tickets, or citations need not be disclosed, it is your responsibility to ensure the offense, arrest, ticket, or citation has, in fact, been expunged or sealed. It is recommended that you obtain a copy of the Court Order expunging or sealing the record in question. Failure to reveal an offense, arrest, ticket, or citation that is not in fact expunged or sealed, raises questions related to truthfulness in addition to questions regarding the offense itself. BLE-10 SI 7-2011.doc 5 NOTE: Orders of Non-Disclosure: Pursuant to the Govt. Code [Sec. 552.142 (b)], if you have criminal matters that are the subject of an order of non-disclosure you are not required to reveal those criminal matters on this form. However, a criminal matter that is the subject of an order of non-disclosure may become a character and fitness issue. Pursuant to other sections of the Government Code [411.081(d), 411.081(i)(5), 411.083(b), 411.084(a), 411.087(a), and 411.100], the Texas Board of Law Examiners is entitled to access criminal history record information that is the subject of an order of non-disclosure. Therefore, if the Board of Law Examiners discovers a criminal matter that is the subject of an order of non-disclosure, even if you properly did not reveal that matter, the Board of Law Examiners may ask you to provide information about that criminal matter. (d) Are you currently the target or subject of a grand jury or other governmental agency investigation? _________ yes or no If you answered “YES” to Question 9(d), provide details on a Continuation Form. _______ Check here if a Continuation Form is attached. (e) Within the period covered, have you filed or been the subject of a petition in bankruptcy? _________ yes or no (1) Were there any allegations of fraud or mismanagement of funds? _________ yes or no (2) Were any adversary proceedings instituted? _________ yes or no If you answered “YES” to any part of Question 9(e), attach a Continuation Form on which you provide details as to your response, including the final or current disposition of the matter. In addition, provide legible copies of the bankruptcy petition, all schedules, discharge order (if applicable), and other pleadings relevant to your responses. If you filed a Chapter 7 Petition that resulted in a discharge, include a statement as to whether any of your scheduled debts were not discharged. _______ Check here if a Continuation Form is attached. (f) Within the period covered, have you been charged with fraud or alleged to have committed fraud in any criminal or civil proceeding? _________ yes or no If you answered “YES” to Question 9(f), attach a Continuation Form on which you provide details as to your response. In addition, provide legible copies of relevant court documents, including pleadings and orders relating to the fraud allegations. _______ Check here if a Continuation Form is attached. 10. Within the period covered, have you abused, been addicted to, or been treated for the use or abuse of alcohol or any other substance, to include any court-ordered treatment? If you answered “YES” to Question 10, provide details on a Continuation Form. Include the dates of treatment and the name, current mailing address, and telephone number of each person who provided evaluation or treatment, as well as the dates of treatment and the name, current mailing address, and telephone number of each facility where you received treatment. _______ Check here if a Continuation Form is attached. BLE-10 SI 7-2011.doc 6 _________ yes or no 11. If you have received mental health counseling or have been hospitalized for mental health reasons and do not know the diagnosis which was made, you should contact the health care provider responsible for your care and inquire as to whether you were diagnosed with bi-polar disorder, schizophrenia, paranoia, or any other psychotic disorder. In answering the following questions, you are entitled to rely on the diagnosis of your treating health care provider. You do not need to report any counseling, treatment, or hospitalization, which was for a diagnosis other than those included in the following questions. A “yes” response to either of the following questions does not mean necessarily that you will be found to lack the fitness required for admission to the Bar. The Board is sensitive to confidentiality concerns. Please refer to Rule I(d) of the Rules Governing Admission to the Bar of Texas concerning confidentiality. (a) Within the period covered, have you been diagnosed with, or have you been treated for, bi-polar disorder, schizophrenia, paranoia, or any other psychotic disorder? _________ yes or no (b) Within the period covered, have you been admitted to a hospital or other facility for the treatment of bi-polar disorder, schizophrenia, paranoia, or any other psychotic disorder? _________ yes or no If you answered “YES” to any part of Question 11, provide details on a Continuation Form. Include date(s) of diagnosis and treatment, a description of your course of treatment and a description of your present condition. Include the name, current mailing address, and telephone number of each person who treated you, as well as each facility where you received treatment, and the reason for each treatment. You may also include information as to why, in your opinion or that of your health care provider, your illness or disorder will not affect your ability to practice law in a competent and professional manner. _______ Check here if a Continuation Form is attached. 12.(a) Within the period covered, have you ever been ordered by a court to pay child support? _________ yes or no If you answered “YES” to Question 12(a), attach a Continuation Form on which you provide the name, current mailing address, and telephone number of the payee and the office (if any) receiving your payments. In addition, provide legible copies of relevant documents (including court orders and agreements incident to divorce). (b) Are you now, or have you been within the period covered, past due in any such court-ordered child support payments? _________ yes or no (c) Within the period covered, have you ever had an arrearage judgment taken against you? _________ yes or no If you answered “YES” to Question 12(b) or (c), explain your response on a Continuation Form. In addition, provide legible copies of relevant documents, including court orders. _______ Check here if a Continuation Form is attached. 13. Within the period covered, have you ever been held in contempt or sanctioned by a court? If you answered “YES” to Question 13, explain your response on a Continuation Form and provide legible copies of the court order(s). _______ Check here if a Continuation Form is attached. BLE-10 SI 7-2011.doc 7 _________ yes or no 14.(a) Do you have any student loan debts that are ninety (90) days or more past due? _________ yes or no If you answered “YES” to Question 14(a), attach a Continuation Form on which you provide the name, mailing address, and telephone number of the creditor(s), the amount owed, the account number, the reason for the delinquency, and your intentions as to the resolution of the debt. _______ Check here if a Continuation Form is attached. (b) Do you have any other debts that are ninety (90) days or more past due (including tax debts owed pursuant to state or federal law)? _________ yes or no If you answered “YES” to any part of Question 14, provide a current credit report from EXPERIAN (1-888-397-3742 or you may obtain a report from the Internet at www.experian.com). When you provide a credit report, list any debts you dispute and explain why you dispute them. Also, list any debts that are ninety (90) days or more past due that are not shown on the credit report. 15.(a) Within the period covered, have you failed to timely file any applicable state or federal income tax return and/or report required by law? _________ yes or no (b) Within the period covered, have you failed to pay any taxes owed pursuant to state or federal law at the time such taxes were due? _________ yes or no (c) Within the period covered, have you collected federal withholding, social security, or Medicare taxes from the wages of your employees, and failed to timely report and forward such monies to the Internal Revenue Service? _________ yes or no If you answered “YES” to any part of Question 15, attach a Continuation Form, providing details. In addition, furnish copies of all correspondence related to the matter(s) covered in your explanation. _______ Check here if a Continuation Form is attached. 16.(a) Do you currently have an application for admission to the bar, or an application to take a bar examination, pending in another jurisdiction? _________ yes or no (b) Within the period covered, have you ever initiated the process to become licensed to practice law, or have you ever filed an application to take a bar examination, in any jurisdiction (including Texas) and were not licensed in that jurisdiction? (This question does not refer to applications to law schools.) _________ yes or no (c) Within the period covered, have you ever filed a law student registration document in any jurisdiction and were not ultimately licensed in that jurisdiction? (This question does not refer to applications to law schools.) _________ yes or no If you answered “YES” to any part of Question 16, provide details on a Continuation Form, including the jurisdiction, dates, and other details. _______ Check here if a Continuation Form is attached. BLE-10 SI 7-2011.doc 8 17.(a) (b) Within the period covered, have you applied for any professional or occupational license? _________ yes or no Within the period covered, have you ever been licensed in any professional or occupational capacity? _________ yes or no If you answered “YES” to Question 17(a) or (b) provide details on a Continuation Form, including license held, or applied for, date issued, and the name, address and telephone number of the licensing authority. If the license was not issued, please explain. _______ Check here if a Continuation Form is attached. (c) Within the period covered, have you ever been disbarred, suspended from practice, disciplined, disqualified, placed on a diversion program, or allowed to resign in lieu of disciplinary action, or has your license ever been qualified or conditioned in any way, as a member of any profession, licensed occupation, or as the holder of any public office? _________ yes or no NOTE: If you have been disciplined for professional misconduct in the course of practicing law, or if you have resigned a law license in lieu of disciplinary action, read Rule IV(e) carefully. You may be prohibited from filing this form. (d) Within the period covered, have there ever been any formal or informal charges, complaints, or grievances filed (regardless the outcome) concerning your conduct as a member of any profession, licensed occupation, or as the holder of any public office? _________ yes or no (e) Are there now pending any formal or informal charges, complaints, or grievances concerning your conduct as a member of any profession, licensed occupation, or as the holder of any public office? _________ yes or no If you answered “YES” to Question 17(c), (d), or (e), provide a narrative statement of the details (stating dates, names and circumstances) on a Continuation Form. Include the name and mailing address of the disciplinary authority in possession of the records of such incidents. _______ Check here if a Continuation Form is attached. 18. Within the period covered, have you been the subject of an investigation for the unauthorized practice of law in Texas or any other jurisdiction? _________ yes or no If you answered “YES” to Question 18, provide details on a Continuation Form, including the name, address, and telephone number of the entity and/or person who conducted the investigation. _______ Check here if a Continuation Form is attached. 19. List four (4) character references who can give information about your past activities and candid opinions concerning your character. Do not list relatives or any person named in your response to Questions 5 (Employment History). (a) ____________________________________________________________________________________________ Name Street Address/P.O.Box ____________________________________________________________________________________________ City State/Country Zip/Postal Code Daytime phone number BLE-10 SI 7-2011.doc 9 (b) ____________________________________________________________________________________________ Name Street Address/P.O.Box ____________________________________________________________________________________________ City State/Country Zip/Postal Code Daytime phone number (c) ____________________________________________________________________________________________ Name Street Address/P.O.Box ____________________________________________________________________________________________ City State/Country Zip/Postal Code Daytime phone number (d) ____________________________________________________________________________________________ Name Street Address/P.O.Box ____________________________________________________________________________________________ City State/Country Zip/Postal Code Daytime phone number 20. If you have not enclosed certain required documentation that must be obtained from third parties, you must make a good faith effort to provide that documentation to the Board within thirty (30) days. If applicable, list on a Continuation Form any documentation you have not provided. _______ Check here if a Continuation Form is attached. Before you complete the following Affidavit, verify that you have fully responded to all items, questions, and statements; and that you have completed your Authorization and Release Forms as well as all required Continuation Forms, Civil Litigation Forms, and Criminal History Forms. AFFIDAVIT Before me, a Notary Public, on this day personally appeared ________________________________________________, (Applicant’s Full Name) who after being duly sworn by me, declared: “I have read the instructions and inquiries that constitute the Supplemental Investigation. No revisions or alterations have been made to the text of any inquiry on this form. I have responded to all inquiries on this form fully and frankly, and all the information contained in my Supplemental Investigation (including any required Continuation Form, Criminal History Form, Civil Litigation Form, Employment Form, or any other information) is true and correct. All documents that I have provided or will provide to the Board, that are not required to be certified copies, are to the best of my knowledge, true and correct copies of the original documents. “I understand that the purpose of all the inquiries in this Supplemental Investigation is to provide to the Board of Law Examiners sufficient information for its investigation as to my present moral character and fitness and my eligibility for admission. I further understand that the fact that the Supplemental Investigation form inquires about a particular matter does not mean that the matter is conclusive as to my present moral character and fitness. I understand that the Board’s inquiries and investigation will cover matters that may or may not be grounds for finding that I lack the present good moral character and fitness required for admission to the Bar of Texas. BLE-10 SI 7-2011.doc 10 “I have read the current version of the Rules Governing Admission to the Bar of Texas and the statutes governing the Board of Law Examiners found in Texas Government Code, Sec. 82.001 et seq. I understand that, until I am licensed to practice law in the State of Texas, it is my responsibility to read any subsequent amendments to the Rules Governing Admission to the Bar of Texas, as well as any subsequent amendments to Sec. 82.001 et seq., Texas Government Code, regardless of whether such amendments are adopted after the filing of this document. “I have read the Texas Disciplinary Rules of Professional Conduct, as shown at www.txethics.org/Rules.aspx. I will abide by the Texas Disciplinary Rules of Professional Conduct and any amendments or changes thereto if I am admitted to the Bar of Texas. “I am aware that until I am certified to the Supreme Court for licensure, I am under an on-going obligation to update my responses on my Supplemental Investigation whenever there is an addition or change to information previously provided to the Board. I will notify the Board, in writing, within 30 days of the occurrence giving rise to the need to add or to change information previously provided and will promptly furnish any additional documentation requested by the Board in connection therewith. “I am aware that I have a duty to, and I agree that I will, advise the Board in writing of any change of address and telephone number, even if such change is only for the summer months, so that the Board can contact me at any time if the need arises. “I further depose that, having submitted the foregoing supplemental investigation using the Board’s web version, no revisions or alterations have been made to the text or questions contained therein; and that if revisions or alterations are made, it is understood by me that the supplemental investigation may be denied, or, if granted, may be revoked, and all fees forfeited.” ___________________________________________ Signature of Applicant Subscribed and sworn to before me on this __________ day of _____________________ , ______________. (Seal) ____________________________________________ Signature of Notary My Commission expires: _____________________ BLE-10 SI 7-2011.doc 11 CIVIL LITIGATION FORM (Use a separate form for each matter requiring a Civil Litigation Form. Make additional copies of this form as needed.) Indicate in the Disposition Section whether the matter has been concluded or is still pending. If you are, or were, a plaintiff, you must complete the Form, but you are not required to attach any documentation. If you were a defendant in a matter that has been concluded, attach a legible copy of the docket sheet. If a judgment was rendered against you, attach a legible copy of the judgment and proof of satisfaction, if applicable. Provide an explanation if the judgment has not been satisfied. If the matter resulted in a settlement, provide a summary of the terms as they relate to you and a statement as to whether you adhered to same. If you are a defendant in a matter that is pending, attach a legible copy of the docket sheet and a legible copy of the most recent petition/complaint. Do not leave any line blank. If a line does not apply, enter 'Does not apply' or N/A on that line. NAME: _______________________________________________________________________________________________________ Last First Middle YOUR ROLE IN THIS SUIT: _____ PLAINTIFF _____ DEFENDANT _____ OTHER: _____________________________ (specify role) CAUSE NUMBER(S): __________________________________________________________________________________________ STYLE: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ TITLE OF COURT: ____________________________________________________________________________________________ MAILING ADDRESS OF COURT: ________________________________________________________________________________ ______________________________________________________________________________________________________________ NAME AND ADDRESS OF YOUR LEGAL COUNSEL IN THIS CASE, IF ANY: _________________________________________ ______________________________________________________________________________________________________________ DISPOSITION: ________________________________________________________________________________________________ ______________________________________________________________________________________________________________ SUMMARY OF THE LITIGATION: (Use Continuation Form for additional space, if necessary.) ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ BLE-10 SI 7-2011.doc 12 CRIMINAL HISTORY FORM (Use a separate form for each incident requiring a Criminal History Form. Make additional copies of this form as needed.) Arrest/offense reports: If any of the offenses you describe resulted from an arrest (as opposed to a citation or a ticket) that occurred within five years of the date you sign this Application, you are responsible for either providing legible copies of the arrest/offense reports for such offenses, or providing proof that you made a written request, to the appropriate entity, for such reports. You are not required to provide copies of any citation or tickets. Court records: If any of the offenses you describe, whether they resulted from an arrest, citation, or ticket, occurred within five years of the date you sign this Application, you are responsible for either providing legible copies of all court records for all such offenses, or providing proof that you made a written request, to the appropriate entity, for such court records. NAME: _____________________________________________________________________________________________ Last First Middle Date of Incident: ______________________________________________________________________________________ Location of Incident: __________________________________________________________________________________ City County/State/Country Arresting/Ticketing Agency: ____________________________________________________________________________ Name of Agency ____________________________________________________________________________________________________ Mailing Address City State/Country Zip/Postal Code Detailed Summary of the events and circumstances leading to this arrest, citation, ticket, and/or criminal charge: (Use Continuation Form, if necessary.) ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ CHARGES. For each charge, indicate whether it was a misdemeanor or a felony: Initial Charge(s): _______________________________ _____ Misdemeanor _____ Felony Ultimate Charge (s): _______________________________ _____ Misdemeanor _____ Felony Plea: _______________________________________________________________________________________________ Disposition: (If probation, deferred adjudication, or deferred prosecution, give summary.) ___________________________ ____________________________________________________________________________________________________ Style and Cause Number(s): ____________________________________________________________________________ Title of Court: ________________________________________________________________________________________ Mailing Address of Court: ______________________________________________________________________________ Name and address of your legal counsel in this case, if any: ___________________________________________________ ____________________________________________________________________________________________________ BLE-10 SI 7-2011.doc 13 CONTINUATION FORM (Use a separate form for each question that requires a Continuation Form. Make additional copies of this form as needed.) For Question No. ________________ NAME: _____________________________________________________________________________________________ Last First Middle ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ BLE-10 SI 7-2011.doc 14 EMPLOYMENT FORM (Make additional copies of this form as needed.) Name of Employer: __________________________________________________________________________________ Current address: ______________________________________________________________________________________ Street/P.O. Box City Telephone number: _____________________________ State/Country Dates employed: _____________________________________ Area Code From (mm/dd/yy) Position Held: ________________________________ Zip/Postal Code To (mm/dd/yy) Name of Supervisor: __________________________________ Reason for leaving: ___________________________________________________________________________________ If this employment is/was self-employment, or if the employer is now out of business, provide the name, current mailing address and telephone number of a verifying reference. Name: ______________________________________________________________________________________________ Address: ____________________________________________________________________________________________ Street/P.O. Box City State/Country Zip/Postal Code Daytime telephone number: _____________________________________________________________________________ Area Code Name of Employer: __________________________________________________________________________________ Current address: ______________________________________________________________________________________ Street/P.O. Box City Telephone number: _____________________________ State/Country Dates employed: _____________________________________ Area Code From (mm/dd/yy) Position Held: ________________________________ Zip/Postal Code To (mm/dd/yy) Name of Supervisor: __________________________________ Reason for leaving: ___________________________________________________________________________________ If this employment is/was self-employment, or if the employer is now out of business, provide the name, current mailing address and telephone number of a verifying reference. Name: ______________________________________________________________________________________________ Address: ____________________________________________________________________________________________ Street/P.O. Box City State/Country Zip/Postal Code Daytime telephone number: _____________________________________________________________________________ Area Code BLE-10 SI 7-2011.doc 15 Board of Law Examiners Appointed by the Supreme Court of Texas Authorization and Release I, ________________________________________, born in ______________________________________________ (Applicant’s Full Name) (City / State / Country) hereby give my consent to the Board of Law Examiners to conduct an investigation as to my moral character and fitness and to make inquiries and request such information from third parties as, in the sole discretion of the Board, is necessary to such investigation. I further authorize the use of any such information in the course of the Board’s investigation and evaluation of my moral character and fitness. I authorize and request every person, firm, company, corporation, school, employer (past or present), governmental agency, court, association, institution, or other third party having opinions about me or knowledge or control of any information, documents, records (including but not limited to public or private disciplinary records, criminal history record information, medical or psychological records), or other data pertaining to me, to reveal, furnish and release to the Board of Law Examiners of the State of Texas, or any of its agents or representatives, any such opinions, knowledge, information, documents, records or other data. Without limiting the previously described authority, I specifically authorize the release of files of any bar association, grievance or other bar committee regarding charges or complaints filed against me, formal or informal, pending or closed, or any other pertinent data, as well as all undergraduate, graduate, or law school records relating to my admission to and conduct during my enrollment in such schools. I hereby release, discharge and hold harmless the Board of Law Examiners of the State of Texas, its agents or representatives (including but not limited to expert witnesses or evaluators consulted or used by the Board or its staff in the course of its investigation), and any person, firm, company, corporation, school, employer (past or present), governmental agency, court, association, institution, or other third party, and their agents, from any and all liability of every nature and kind arising out of the furnishing, inspection, and use of such opinions, knowledge, documents, records or other data. Notwithstanding any statement herein to the contrary, this Authorization and Release shall operate to agree to the release of only those mental health records relating to the following: (a) my being diagnosed with bi-polar disorder, schizophrenia, paranoia, or any other psychotic disorder, and any treatment therefor, within the ten (10) years immediately preceding the filing of my Application with the Board of Law Examiners; and (b) my admission to a hospital or other facility for the treatment of bi-polar disorder, schizophrenia, paranoia, or any other psychotic disorder, since attaining the age of eighteen or within the ten (10) years immediately preceding the filing of my Application, whichever period is shorter. This limitation, however, does not apply to records relating to chemical dependency nor to any records relating to a disability for which I am seeking or intend to seek nonstandard testing accommodations. ___________________________________________ Signature of Applicant Subscribed and sworn to before me on this __________ day of _______________________ , ______________. (Seal) ___________________________________________ Signature of Notary My Commission expires: ______________________ BLE-10 SI 7-2011.doc 16 Board of Law Examiners Appointed by the Supreme Court of Texas Authorization and Release I, ________________________________________, born in ______________________________________________ (Applicant’s Full Name) (City / State / Country) hereby give my consent to the Board of Law Examiners to conduct an investigation as to my moral character and fitness and to make inquiries and request such information from third parties as, in the sole discretion of the Board, is necessary to such investigation. I further authorize the use of any such information in the course of the Board’s investigation and evaluation of my moral character and fitness. I authorize and request every person, firm, company, corporation, school, employer (past or present), governmental agency, court, association, institution, or other third party having opinions about me or knowledge or control of any information, documents, records (including but not limited to public or private disciplinary records, criminal history record information, medical or psychological records), or other data pertaining to me, to reveal, furnish and release to the Board of Law Examiners of the State of Texas, or any of its agents or representatives, any such opinions, knowledge, information, documents, records or other data. Without limiting the previously described authority, I specifically authorize the release of files of any bar association, grievance or other bar committee regarding charges or complaints filed against me, formal or informal, pending or closed, or any other pertinent data, as well as all undergraduate, graduate, or law school records relating to my admission to and conduct during my enrollment in such schools. I hereby release, discharge and hold harmless the Board of Law Examiners of the State of Texas, its agents or representatives (including but not limited to expert witnesses or evaluators consulted or used by the Board or its staff in the course of its investigation), and any person, firm, company, corporation, school, employer (past or present), governmental agency, court, association, institution, or other third party, and their agents, from any and all liability of every nature and kind arising out of the furnishing, inspection, and use of such opinions, knowledge, documents, records or other data. Notwithstanding any statement herein to the contrary, this Authorization and Release shall operate to agree to the release of only those mental health records relating to the following: (a) my being diagnosed with bi-polar disorder, schizophrenia, paranoia, or any other psychotic disorder, and any treatment therefor, within the ten (10) years immediately preceding the filing of my Application with the Board of Law Examiners; and (b) my admission to a hospital or other facility for the treatment of bi-polar disorder, schizophrenia, paranoia, or any other psychotic disorder, since attaining the age of eighteen or within the ten (10) years immediately preceding the filing of my Application, whichever period is shorter. This limitation, however, does not apply to records relating to chemical dependency nor to any records relating to a disability for which I am seeking or intend to seek nonstandard testing accommodations. ___________________________________________ Signature of Applicant Subscribed and sworn to before me on this __________ day of _______________________ , ______________. (Seal) ___________________________________________ Signature of Notary My Commission expires: ______________________ BLE-10 SI 7-2011.doc 17