UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK
CJA PANEL APPLICATION FORM
PLEASE COMPLETE THE ATTACHED CRIMINAL JUSTICE ACT 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
CRIMINAL JUSTICE ACT ASSIGNED COUNSEL 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)* Federal Tax Identification No.: __________________ 7A)* Social Security No.: ___________________
8) Education: Law School:_____________________________________________________________ Date:__________ College: _____________________________ Highest Degree obtained: ___________ Date:__________ College: _____________________________ Highest Degree obtained: ___________ Date:__________ Other: _________________________________________________________________________________ 9) Dates of Admission :
A) Federal Court - Northern District of New York : _________/________/_________ B) State Court - New York State:___________/________/___________
C) Other (Circle Circuit, Federal, State, or County, indicate name of Court or Bar, and list admission date for each): Circuit / Federal / State / County ______________________________________________________ Circuit / Federal / State / County ______________________________________________________ Circuit / Federal / State / County ______________________________________________________ Admission Date: ________/________/________ Admission Date: ________/________/________ Admission Date: ________/________/________
10) I am fluent in a foreign language(s):
YES /
NO
--> If Yes, please Specify:______________
11) Have you ever declined a CJA Panel assignment from this Court? NO / YES If Yes, state circumstances: _____________________________________________________________ 12) I am familiar with the current NDNY Local Rules I am familiar with the current Fed.R.Crim.P. --> YES / NO --> YES / NO
* IF USING A LAW FIRM EMPLOYER IDENTIFICATION NUMBER, YOU MUST ALSO PROVIDE YOUR SOCIAL SECURITY NUMBER
13)
A) CRIM INAL CAS E EXP ERIEN CE: 1) Num ber of N DN Y Fe deral Defe ndan ts Rep resented :______ __ (List below inform ation on the 3 m ost recen t) Case Numb er: __________CR_________ Judge: _______________ Disposition: __________________________ Cas e Nu mber: _________CR_________ Judge: _______________ Disposition: __________________________ Case Num ber: _________CR_________ Judge: _______________ Disposition: __________________________ 2) D eath Pen alty C ase s: ____ I h ave rep rese nted a D eath Pen alty d efen dant at trial ____ I have represented a convicted Death Penalty defendant on a Habeas petition 3) Experience Applying Federal Sentencing Guidelines - As to criminal cases mentioned above in 13A1, list specific examples of how you applied or utilized Federal Sentencing Guidelines: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ B) APPELLATE EXPERIENCE: 1) Number of Federal Criminal Appeals: ________ Number of State Appeals:________
C) Other Relevant Training or Experience not previously listed:__________________________________________
14) CONTINUING LEGAL EDUCATION: A) Have you completed any courses on the Sentencing Guidelines? YES / NO B) Have you completed any courses on the Bail Reform Act? YES / NO
Date:_______________ Date:_______________
C) Have you attended FPD sponsored CLE programs? YES / NO (If yes, list below) Program name:________________________________________ Date attended: __________________ Program name:________________________________________ Date attended: __________________ Program name:________________________________________ Date attended: __________________ D) What CLE programs have you participated in (not already mentioned in #14C): Program name:________________________________________ Date attended: __________________ Program name:________________________________________ Date attended: __________________ Program name:________________________________________ Date attended: __________________ E) Have you participated in the Northern District CJA Training Panel - 2nd Chair Program? Date completed:___________________________________ Dated: ____________________ ____________________________________ Signature ------------------------------------------------------------------------------------------------------------------------------------------FOR CJA PANEL COMMITTEE USE ONLY:
____ APPROVAL RECOMMENDED ____ ADDITIONAL TRAINING RECOMMENDED ____ APPROVAL NOT RECOMMENDED
Date: _______________ ___________________________________________ CJA Panel Committee ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------FOR BOARD OF JUDGES USE ONLY:
Attorney is added to the Panel list for the following regional area of the NDNY: Albany Binghamton Syracuse Utica Watertown
Date: ________________ ____________________________________________ Hon. Norman A. Mordue, Chief Judge
CJA Panel Application 10/10/03