CHESAPEAKE CIRCUIT COURT 307 Albemarle Drive Suite 400A Chesapeake, Virginia 23322 (757) 382-3061 APPLICATION FOR INCLUSION ON COURT APPOINTED LIST 1. Name: 2. Business Address: 3. Telephone #: Cellular #: (H) Pager #: (W) Fax #: 4. Fill in one of the following for reporting purposes: S.S. # or Taxpayers ID # 5. Educational Background: Please attach 6. Date admitted to Virginia Bar: 7. Years of experience regarding criminal cases: 8. Are you presently under any legal or other disability which prevents you from practicing law in the Commonwealth of Virginia? Have you been subject to any legal disciplinary proceedings within the last 5 years? Have you received any official notice within the last months of any licensing or legal disciplinary proceeding which may be or have been filed against you. yes: No: 9. If your answer to any of these questions is yes, please explain on a separate paper or contact the Chief Judge for a persona l, confidential interview. Signature Date: American LegalNet, Inc. www.USCourtForms.com