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APPLICATION FOR CJA PANEL MEMBERSHIP
Please answer all questions. If a question is not applicable, indicate this by marking "N/A."

GENERAL 1. 2. 3. Full name: Business name Office address: City Office Phone Email EDUCATION 4. Colleges and universities attended, dates, and degrees: State Fax _______________________________________ Zip Cell Phone

PROFESSIONAL ADM ISSIONS 5. List all courts (including state bar admissions)in which you are presently admitted to practice, giving the dates of admission in each instance: Court or Administrative Body Date of Admission

6.

Have you ever been disciplined or cited for a breach of ethics or unprofessional conduct by any court, administrative agency, bar association, or other professional group? Yes No. If yes, give particulars.

LAW PRACTICE 7. Provide the following information for your employment for the past five years. Organization Address Position Dates

8.

Describe the general nature of your current practice including any legal specialties and character of your typical clients; also, if your practice is substantially different now than previously, give details of prior practice.

9.

W hat percentage of your court appearances in the last five years were in criminal cases in: 1. Federal courts 2. State or local courts % % _____ %

10.

During the past five years, what percentage of your practice has been criminal trial practice?

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APPLICATION FOR CJA PANEL MEMBERSHIP
11. How frequently have you appeared in court? a) Have you ever been sued by a client? _______ times per month. No.

12.

Yes

If yes, give particulars.

b) Have you or your professional liability insurance carrier ever settled a claim against you for professional malpractice? Yes No. If yes, give particulars, including the amounts involved.

CONDUCT 13. Have you ever been charged in any civil or criminal proceedings with conduct alleged to involve moral turpitude, dishonesty, or unethical conduct? Yes No. If yes, give particulars.

14.

a) Have you ever been arrested, charged, or convicted for violation of any federal law, state law, county or municipal law, regulation, or ordinance? Yes No. If yes, give details. (Do not include traffic violations for which a fine of $200 or less was imposed unless it also included a jail sentence.)

b) Have you, to your knowledge, ever been under federal, state or local investigation for possible violation of a criminal statute? Yes No. If yes, give particulars.

15.

Have you in the last 10 years (i) been hospitalized due to injury or serious mental or physical illness or drug or alcohol addiction, or (ii) been prevented from working or otherwise incapacitated for a period in excess of ten days due to injury or illness, drug or alcohol addiction? If so, give the particulars, including the causes, the dates, the places of confinement, and the present status of the conditions which caused the confinement or incapacitation.

SUPPLEM ENTAL INFORM ATION 16. State any achievements or actions you have accomplished, demonstrating your commitment to equal justice under the law.

17.

State any other pertinent information reflecting positively or adversely on you which you believe should be disclosed. Language Proficiency (including sign language):

18.

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APPLICATION FOR CJA PANEL MEMBERSHIP

I declare under penalty of perjury that the foregoing is true and correct.

Signature of Applicant

Date

CONFIDENTIALITY STATEM ENT This form will be kept confidential and will be examined only by the judges of the district court and others necessary to review of panel applications.

Submit this form to:
Chief Magistrate Judge David Nuffer Room 483 Frank E. Moss United States Courthouse 350 South Main Street Salt Lake City, UT 84101 .

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