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UNITED STATES DISTRICT COURT SOUTHERN DISTRICT OF INDIANA APPLICATION FOR MEMBERSHIP ON CIVIL LEGAL ASSISTANCE PANEL I, , having been admitted to practice before the United States District Court for the Southern District of Indiana and being a member in good standing of the Bar of such Court, do hereby apply for membership in the Civil Legal Assistance Panel of that Court. In support of this application I have supplied the following information: Full Name: Firm or Business: Business Address: Business Telephone.: Specialized Area of Law (if any): Year of Admission to the Southern District of Indiana:

Please rank, in order of preference ("1" being the most preferred, "5" being the least preferred) your preference for accepting a case which involves the following types of matters: Employment discrimination action Civil rights action filed by person in custody Other civil rights action Social Security appeal Other action - state preference:

If you are able to consult and advise in languages other than English, please indicate below:

G

Spanish

G

Other:

Please indicate your preference as to level of involvement: __________ __________ __________ Handle entire litigation through trial, or if not, would prefer to: Assist litigant with discovery Assist litigant with making and responding to dispositive motions (e.g. motion to dismiss, motion for summary judgment) Serve as stand-by counsel at trial Assist another attorney who has primary responsibility for case

__________ __________

Please check below if you would you consider: __________ __________ Sharing responsibility for a case with another lawyer Working with a law student assigned to the case, who could assist with research, drafting, investigation

Please indicate all Divisions of this court in which you are willing to accept a case:

G G

Indianapolis Evansville

G G

Terre Haute New Albany

In making this application, I represent that I am willing to represent civil litigants determined to be eligible for representation under any applicable statutory authority and for whom the request for counsel has been made pursuant to Rule 4.6 of the Local Rules of the United States District Court for the Southern District of Indiana. I recognize that I may decline a request by the court for representation of an individual but I will make a reasonable effort to accept a request when I am able to do so. In addition, I shall supplement this Application in writing from time to time as requested by the Court and as circumstances warrant so as to keep the Court informed of any change in my address or other information relevant to my membership on the Civil Legal Assistance Panel.

Date:

Signature:

For use by the Court Appointed to Civil Legal Assistance Panel of Attorneys on Member of sub-panel for the Division. District Court Clerk United States Courthouse, Room 105 46 East Ohio Street Indianapolis, Indiana 46204 , 20 .

Execute original only and return to:

If you have any questions, please call (317) 229-3705