APPLICATION FOR GUARDIAN AD LITEM REGISTRY Family Law ­ Title 26 Mail or deliver the completed application, with all attachments, to: Kitsap County Superior Court Administrator 614 Division Street, MS-24 Port Orchard, WA 98366 Name: Business Name or Firm: Business Address: City and State: Business Phone: ( Email Address: Non-Attorney Attorney - WSBA or Washington State Certification No: ______________________________ I am willing to serve as a Guardian ad Litem for Guardianships at public expense. I have no pending investigations or action against me involving felony allegations, professional certification or license suspension and/or revocation. I agree to advise the court immediately in the event of any complaint, investigation or action being commenced which could lead to professional discipline, or the suspension or revocation of my professional license, or to the filing of criminal charges for felony or crime involving allegations of theft, dishonesty or moral turpitude. I have read and agree to be bound by the Kitsap County Superior Court Guardian ad Litem Registry Code of Conduct. Summary of my experiences as a GAL including years of experience and number of appointments. ) Fax: ( Zip Code: ) Number of times serving as a Guardian as Litem that I have been removed for failure to perform my duties as a Guardian ad Litem: _____________________________________________________ TITLE 26 GAL REGISTRY APPLICATION . . 1 G:\SCRT\DATA\GAL\GAL-26 Registry Application.doc American LegalNet, Inc. www.FormsWorkFlow.com I include the following with my application (please check all applicable boxes): Curriculum vitae, showing work and professional or personal experience in or related to the field that would assist in the performance and completion of Guardian ad Litem duties. Completed Washington State Patrol Conviction Criminal History. Signed release of information directed to all professional regulatory bodies which have licensed or supervised the applicant within the last ten years. Description of nature, status and outcome of any professional complaints, investigations or disciplinary actions, lawsuits or professional liability claims, and any order for removal of the Guardian ad Litem prior to completion of the Guardian ad Litem's duties. Description of any claims or litigation that has been commenced, involving allegations of improper fee charges, charges of fraud, theft or other forms of dishonesty or professional malpractice or misconduct. Copy of fee schedule. Certificate of Qualification/Training for Guardian ad Litem seeking appointment under RCW Title 26. OR I am currently on the Guardian ad Litem Registry and have included a certificate of updated training taken within the two years. I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. DATED this _______ day of _________, 20____, at _______________________, Washington. SIGNATURE OF APPLICANT PRINT NAME: TITLE 26 GAL REGISTRY APPLICATION . . 2 G:\SCRT\DATA\GAL\GAL-26 Registry Application.doc American LegalNet, Inc. www.FormsWorkFlow.com