APPLICATION FOR PIERCE COUNTY SUPERIOR COURT TITLE 11 GUARDIAN AD LITEM REGISTRY TITLE This application is for Guardians ad Litem who are not currently serving on the Pierce County Superior Court Title 11 Guardian ad Litem Registry. THIS IS PUBLIC INFORMATION This is my application to serve as a Guardian ad Litem in Pierce County, State of Washington as required under RCW Title 11. I hereby certify under the penalty of perjury under the laws of the State of Washington that my application is true and correct. Signed in: ___________________________ (City), Washington on ________________________ (Date) Signature:_________________________________________________ WSBA # and Year Admitted to Practice in the State of Washington: ______________________________ If a current or inactive member of another state's bar association, please indicate bar association number and year admitted to practice, and if applicable, year you became inactive: ________________________ Printed Name: ______________________________________________________________________ Business Address: ________________________________________________________________ City: ______________________________ State: ___________ Zip Code: ________________________ Business Telephone Number: ___________________________ FAX: ___________________________ E-Mail Address: ______________________________________________________________________ Bilingual: ________________________ If so, in what language(s): ______________________________ Please indicate the county, date and location where you are enrolled for the two day mandatory training (only approved training qualifies) if not completed by the application closing date, March 22, 2013. NOTE: If you are not currently serving on any other county's RCW 11.88 certified GAL Registry, you are required to attend both days of the mandatory training held in the same year in which you apply. (Apply in January 2013, attend 2 day training in May 2013, not May 2012.) Training Sponsored by: (Name) ___________________________________________________ (Address) _________________________________________________ (County) _________________________ (Dates) _____________, 2011 (Phone) ___________________________________________________ NOTE: Only this application may be utilized. A checklist is included since late and incomplete applications shall not be accepted for any reason. All questions must be answered in the order in which they are given. Answers that only refer to a resume or vitae are not acceptable although a resume is required and you may attach supporting materials. Please return completed application, resume and any materials by March 22, 2013 4:30 PM to: Pierce County Superior Court Administrator Room 334, County City Building 930 Tacoma Ave South Tacoma, WA 98402-2108 Title 11 GAL Registry Application Revised 12/5/2012 1 American LegalNet, Inc. www.FormsWorkFlow.com THIS PART OF THE APPLICATION IS PUBLIC INFORMATION A. Level of formal education, indicating university issuing the degrees and years obtained: B. Please list all trainings you have attended, the sponsor, month/year attended and the materials covered in each training that relate to Title 11 Guardian ad Litem statutory duties. Attach all Certificates of Attendance/Completion. C. Number of years' experience as a Guardian ad Litem under RCW 11.88.090: 1) List year and all counties where you first served on any certified RCW 11.88.090 Guardian ad Litem Registry. 2) List each year and all counties where you have been appointed to serve on a RCW 11.88.090 Guardian ad Litem Registry. D. Number of appointments you have received as an 11.88.090 Guardian ad Litem and all counties of appointment during the last Registry year, 3/21/12 to 3/22/13, if served on any other county Guardian ad Litem Registry: Appointments in Pierce County: Appointments in __________________County: Appointments in __________________County: E. Percentage of your total case load that RCW Title 11 Guardian ad Litem work represents overall: F. Criminal history, as defined in RCW 9.94A.030: A current (dated on or after January 2, 2013) and completed Washington State Patrol Conviction Criminal History Record must be received by the Court. If not attached, the expected date the Court will have the record: ____________ Title 11 GAL Registry Application Revised 12/5/2012 2 American LegalNet, Inc. www.FormsWorkFlow.com G. Have you ever been accused of, found guilty of, or been a victim of either domestic violence or an anti-harassment action? Yes _____ No ______. If yes, please explain. H. Evidence of your knowledge, training, and experience, in the following areas, pursuant to RCW 11.88.090 (3) (b) (I). You must complete in full the information requested below, in the space provided, in addition to attaching the required resume or vitae. However, answers that only refer to a resume or vitae are not acceptable. 1) The needs of impaired elderly: 2) Understanding of issues surrounding abuse and neglect of the elderly: 3) The needs of persons with physical disabilities: 4) The needs of persons with mental illness: 5) The needs of persons with developmental disabilities: 6) Other areas relevant to the needs of incapacitated persons: 7) Legal procedures and Guardian ad Litem requirements of RCW 11.88: Title 11 GAL Registry Application Revised 12/5/2012 3 American LegalNet, Inc. www.FormsWorkFlow.com 8) The number of times you have been removed for failure to adequately perform your duties as Guardian ad Litem or for other cause. For each removal, give a brief explanation with the county, case name and cause number, and attach all relevant documents from the court file along with a copy of the court order of removal. I also certify the following: I. I will successfully complete the two day mandatory Guardian ad Litem training required by the Pierce County Superior Court (only approved training qualifies) and under the laws of the State of Washington and immediately submit my Certificate of Attendance. AGREE ______ DISAGREE______ J. My normal hourly rate is $_________. My hourly rate to serve as an 11.88.090 Guardian ad Litem in guardianships is $_____________. K. I am presently not serving, nor have I recently applied to serve, as a Judge or Commissioner pro tempore in Pierce County Superior Court. I understand that I am not permitted to serve in both capacities. AGREE ______ DISAGREE______ L. I have no criminal history or license suspension or revocation. AGREE ______ DISAGREE___