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Assigned Counsel Application Form Admission To The CJA Panel - New York
| Assigned Counsel Application Form Admission To The CJA Panel Form. This is a New York form and can be used in Northern District District Court Federal . |
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UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK CJA PANEL APPLICATION FORM PLEASE COMPLETE THE ATTACHED CRIMINAL JUSTICE ACT PANEL APPLICATION FORM. ~~~~~~ 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 American LegalNet, Inc. www.USCourtForms.com 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 American LegalNet, Inc. www.USCourtForms.com 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: Date: _______________ ___________________________________________ CJA Panel Committee ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------FOR BOARD OF JUDGES USE ONLY: ____ APPROVAL RECOMMENDED ____ ADDITIONAL TRAINING RECOMMENDED ____ APPROVAL NOT RECOMMENDED 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 American LegalNet, Inc. www.USCourtForms.com
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