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BENCH-BAR COMMITTEE APPLICATION FOR MEMBERSHIP

Please complete the following application and attach a current copy of your resume. If additional space is needed, please use the reverse of this form.
Name: Firm Name: Address: Phone: E-Mail Address: College and undergraduate degree: Law school and date of graduation: Date(s) of admission to practice: Supreme Court of Kansas Nature/Area of Practice: State Civil Plaintiff Area(s) of Specialization: US District Court Federal Criminal Defendant Other(s) (specify) In-house counsel

Explain why you are interested in serving on this committee:

Past service on any federal court committee(s):

Bar membership and other extracurricular activities:

Please answer the following questions regarding disciplinary matters: I am in good standing in all bars of which I am a member. Yes No
Please explain on reverse next page

No disciplinary or grievance proceedings have been previously filed against me nor are any pending True False Please explain on reverse against me in any jurisdiction. Please explain on next page I have not been charged in any court of the United States or of any state, territory or possession of the United States with the commission of a felony or unprofessional conduct. True False Please explain on reverse next page

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BENCH-BAR COMMITTEE APPLICATION FOR MEMBERSHIP Page Two