APPLICATION FOR GUARDIAN AD LITEM REGISTRY Guardianship/Probate/Trust ­ Title 11 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: ) Fax: ( ) Zip Code: 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. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 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: ________________________________________________________________ Page 1 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; Copies of any any professional complaints, investigations or disciplinary actions, lawsuits or professional liability claims filed, whether pending or completed, including a statement for each setting out the current status and any applicable response to said claims; Copies of 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; AND, EITHER Certificate of Qualification/Training for Guardian ad Litem seeking appointment under RCW Title 11, OR I am currently on the Guardian ad Litem Registry and have included a certificate of updated training taken within the last year I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. DATED: Signature of Applicant ______________________________ City Where Signed : Printed Name Page 2 American LegalNet, Inc. www.FormsWorkFlow.com