Free Criminal Justice Act Assigned Counsel and Civil Pro Bono Application Form (Western District of - Wisconsin

CRIMINAL JUSTICE ACT ASSIGNED COUNSEL AND CIVIL PRO BONO APPLICATION FORM Western District of W isconsin Please complete the following application form. We will use the information provided to match panel attorneys with cases, taking into account background and experience. Thank you for your interest in serving as a volunteer attorney in this court. PLEASE RETURN YOUR COMPLETED APPLICATION TO: Magistrate Judge Stephen L. Crocker U.S. District Court, W.D . Wisconsin P.O. Box 591 Madison, WI 53701

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NAME:_________________________________________ Date of Birth:______________ Law firm name: Office address: ________________________________________________________ _________________________________________ _________________________________________ Office Telephone No.___________________ Fax No.________________

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EDUCATION AND BAR MEMBERSHIP Graduated from ______________________________ School of Law Year Graduated:_______________ ___ Admitted to practice in the Western District of Wisconsin. ___ Admitted to practice in the State of Wisconsin courts. ___ Admitted to practice in the 7th Circuit Court of Appeals. Please list any other court admissions, including the admission date(s). ______________________________________________________________________________ Date:__________ Date:__________ Date:__________

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AREAS OF INTEREST Please indicate the types of cases for which you would like to be appointed: ____ ____ ____ ____ Criminal Habeas Corpus 42 U.S.C. § 1983 (primarily prisoner civil rights) Social Security Appeals

Areas of Special Interest:________________________________________________________

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EXPERIENCE Please provide a brief description of your legal experience. ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ State briefly the nature of your present practice:_______________________________ Please indicate by approximate number your trial experience: Federal criminal trials:_______ State court trials: Felonies_______ Misdemeanors_______ State court pleas and sentences:_______

Federal court pleas and sentences:_______ Civil trials: Federal _______ State _______ Social Security Appeals:_______

Please indicate any areas in which you have special skills or expertise (e.g. computers, accounting, DNA, etc.)_________________________________________________________ ______________________________________________________________________________

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CRIMINAL JUSTICE ACT INFORMATION Complete this section only if you are interested in accepting appointments in criminal or habeas corpus cases. Do you have experience working with the Federal Sentencing Guidelines?________ Have you taken any CLE courses or attended any training sessions which covered the Federal Sentencing Guidelines?________ Title of course(s):________________________________________________ Date:____________ ________________________________________________ Date:____________ Do you believe you know and understand the Federal Sentencing Guidelines well enough to adequately represent federal defendants?_________ Do you have experience working with the federal habeas corpus statutes, 28 U.S.C. §2254 or § 2255?____________

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REFERENCES Please provide as a reference the name, address and telephone number of at least one attorney who practices in the Western District of Wisconsin: ________________________________________________ Name ________________________________________________ Address ___________________________ Phone

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ADDITIONAL INFORMATION Can you speak any foreign languages?_____ Please specify:_________________________ Are there any types of cases (e.g. drug cases, bank robbery) that you would prefer not to take?_________________________________________________________________________

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If you are relatively inexperienced, would you be willing to work under the guidance of a mentor?___________ If you are inexperienced, would you be willing to second-chair, without compensation, a more experienced attorney?____________ If you are an experienced attorney, would you be willing to have an inexperienced attorney or law student "shadow" you?___________

I hereby certify the above information is true and correct.

_______________________________________ Attorney's signature

Date:________________

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