NAME:

EMAIL ADDRESS:

FIRM NAME:

OFFICE STREET ADDRESS:

CITY, STATE, ZIP CODE:

PHONE:

FAX:

WSBA NO.:

LIST ALL STATES AND COURTS IN WHICH YOU ARE ADMITTED TO PRACTICE
AND IN GOOD STANDING AND THE YEARS ADMITTED:

HAVE YOU EVER BEEN DISCIPLINED BY THE BAR OF ANY STATE OR
BY ANY COURT?:

IF YES, PLEASE DETAIL BELOW:

NAME OF LAW SCHOOL:

YEAR GRADUATED:

NAME OF UNDERGRADUATE SCHOOL:

DEGREE OBTAINED AND YEAR GRADUATED:

NAME OF ANY OTHER POST-GRADUATE SCHOOL:

DEGREE OBTAINED AND YEAR GRADUATED:

BRIEFLY DESCRIBE YOUR OTHER EMPLOYMENT EXPERIENCE SINCE
GRADUATING FROM LAW SCHOOL:

BRIEFLY STATE THE NATURE OF YOUR PRESENT PRACTICE:

SPECIFY THE NUMBER OF CASES IN EACH CATEGORY:

CIVIL OR CRIMINAL TRIALS, FEDERAL:

CIVIL OR CRIMINAL TRIALS, STATE:

CIVIL OR CRIMINAL APPEALS, FEDERAL:

CIVIL OR CRIMINAL APPEALS, STATE:

OTHER (DESCRIBE):

TRAINING OR EXPERIENCE THE COURT SHOULD CONSIDER TO ASSESS
YOUR QUALIFICATIONS FOR THIS PANEL:

BRIEFLY DESCRIBE THE SKILLS/ATTRIBUTES THAT BEST SUIT YOU FOR
APPOINTMENT TO THE PANEL OR PROVIDE ANY OTHER INFORMATION THAT
IS RELEVANT TO YOUR APPLICATION: