UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK
PRO BONO PANEL APPLICATION FORM
PLEASE COMPLETE THE ATTACHED PRO BONO PANEL APPLICATION FORM.
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PLEASE RETURN THE COMPLETED FORM TO:
LAWRENCE K. BAERMAN, CLERK UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK P.O. BOX 7367 100 SOUTH CLINTON STREET SYRACUSE NY 13261-7367 ATTN: Tracey Donovan
UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK
PRO BONO PANEL
APPLICATION FORM
1) Name: _____________________________________________________________________________
(LAST) (FIRST) (MIDDLE INITIAL)
2) Firm Name: ________________________________________________________________________ 3) Office Address:______________________________________________________________________ ______________________________________________________________________
(CITY) (STATE) (ZIP CODE)
4) County:__________________________ NDNY Bar Roll No:________________________________ 5) Office Telephone No.: (_____)____________ Fax Number:(______)__________________________ 6) Home Telephone No: (_____)____________ E-Mail Address:_______________________________ 7) Education: Law School:_____________________________________________________ Date:_________ College: __________________________Highest Degree obtained: __________ Date:_________ College: __________________________Highest Degree obtained: __________ Date:_________ Other: ____________________________________________________________________________ 8) Dates of Admission :
A) Fed eral C ourt - N orthe rn D istrict of N ew Yo rk : _________/________/________ B) State Court - New York State:________/_____ _/___ ___
C) O ther (C ircle C ircuit, Feder al, State, or Co unty, indicate nam e of C ourt o r Bar , and list admission date for e ach): Circ uit / Feder al / State / Coun ty __________________________________________________ Circuit / Federal / State / County __________________________________________________ Circ uit / Feder al / State / Coun ty __________________________________________________ Adm ission D ate: ________/________/________ Admission Date: ________/________/________ Adm ission D ate: ________/________/________
9) I am fluent in a foreign language(s):
YES /
NO
--> If Yes, please Specify:_______________
10) I have experience in the following areas of the law (check all that apply) :
Civ il Rights (42 USC 1983) ___ Non-Prisoner Civil Rights Primary Area of Practice: Public Positions Held: Co ntract Labor Law T o r t / P er so n al I nj ur y Ed uc atio n L aw Social Security ___ E nv iron m en tal ___ Bankruptcy Other
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Northern District of New York Pro Bono Panel Application Page 2
11) Civil Case Experience:
1) Number of NDNY Federal Civil Cases:__________ (List below information on the 3 most recent) Case Number: ________CV__________ Judge:_______________ Disposition: _________________ Case Number: ________CV__________ Judge:_______________ Disposition: _________________ Case Number: ________CV__________ Judge:_______________ Disposition: _________________
2) Number of Federal Civil Appeals handled:_______________
Dated: ____________________
____________________________________ Signature
------------------------------------------------------------------------------------------------------------------------------FOR INTERNAL USE ONLY:
Date added to Pro Bono Panel: _______________
w:\pro bono\application 4/8/02
Attorney Admissions Clerk: ________________________