Application For Reinstatement {JD-GC-23}

(Page 1 of 6)APPLICATION FOR REINSTATEMENT JD-GC-23 Rev. 10-17 P.B. 247 2-53Instructions 1. To be completed by suspended, disbarred or resigned attorneys. 2. All sections must be completed or the application will be returned. 3. This is a continuing application. The applicant must provide all new or updated information on a timely basis. 4. Attach additional sheets as necessary to answer any question. For each additional sheet, identify the specific Section for which the applicant is providing additional information. 5. The applicant should maintain a copy for his or her records. 6. File this application with the clerk of the superior court for the jurisdiction that issued the discipline. Pursuant to section 2-53 of the Practice Book, I, the undersigned applicant, submit this application for reinstatement to practice as an attorney in Connecticut, and in support of such application I submit the following sworn statement and attachments. I have read section 2-53 of the Practice Book and the Rules of Professional Conduct. ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA.Section 1. Biographical Information Full name (Last, first, middle) Juris number Birth year Current street address (a street address is required: a P.O. box number only is not acceptable) City State Zip code Telephone number E-mail addressSection 2. Mandatory section 2-53(d) of the Practice Book RequirementsCheck off compliance with section 2-53(d) of the Practice Book and attach proof of compliance with each requirement to your application.I paid the Connecticut Bar Examining Committee the application fee. N/A YesI took the Multistate Professional Responsibility Examination in the past six months onand received a passing score which was sent to the Connecticut Bar Examining Committee.I am in compliance with sections 2-27(d), 2-70 and 2-80 of the Practice Book. This includes having registered (suspended attorneys only) and having paid all fees and restitution due to the Client Security Fund.STOP! IF YOU HAVE NOT COMPLETED THE ABOVE REQUIREMENTS, YOU ARE NOT ELIGIBLE TO APPLY FOR REINSTATEMENT. THIS APPLICATION WILL BE RETURNED TO YOU AS INCOMPLETE WITHOUT A PUBLIC HEARING. IF YOU SELECTED N/A BECAUSE THE COURT HAS EXEMPTED YOU FROM COMPLYING WITH THIS REQUIREMENT, ATTACH A COPY OF THE COURT ORDER TO YOUR APPLICATION.I fully complied with all court ordered conditions imposed pursuant to the order of discipline or I have received relief from that condition from the court.I have successfully completed any criminal sentence including, but not limited to, a sentence of incarceration, probation, parole, supervised release, or period of sex offender registration and I have fully complied with any orders regarding conditions, restitution, criminal penalties or fines. Yes N/AI am no longer the subject of any pending disciplinary proceedings or investigations. N/A Yes Yes N/A Yes N/A N/A Yes American LegalNet, Inc. www.FormsWorkFlow.com (Page 2 of 6)JD-GC-23 Rev. 10-17Section 3. Residence HistoryList in chronological order every residence, whether permanent or temporary, for more than thirty days, since you were suspended, disbarred or resigned. From To Street City State Zip code From To Street City State Zip code From To Street City State Zip codeSection 4. Licensing Status No YesHave you ever applied for reinstatement to the Connecticut bar? If yes, provide the following information as well as a copy of the standing committee's recommendation and the court decision. Case name Docket or complaint number Date of decision Decision No YesHave you ever been investigated for the unauthorized practice of law in any jurisdiction? If yes, explain the circumstances and the result(s) below: List in chronological order any and all attorney discipline issued in Connecticut or any other jurisdiction against your license. Provide copies of every decision. If any conditions were ordered, attach proof that you complied with the ordered conditions. This includes private discipline. Case name Docket or complaint number Date of decision Discipline ordered Case name Docket or complaint number Date of decision Discipline ordered Case name Docket or complaint number Date of decision Discipline ordered No YesHas your license ever been deactivated pursuant to section 2-56 of the Practice Book (Inactive due to disability)? No YesHas your license ever been suspended for failure to pay the Client Security Fund fee? If yes, provide the following information: Date of suspension Date of reinstatement No YesAre you or have you ever been a member of the bar of another jurisdiction, including federal admission? If yes, provide the following information: Jurisdiction Date of admission License number Current status of license Jurisdiction Date of admission License number Current status of license American LegalNet, Inc. www.FormsWorkFlow.com (Page 3 of 6)JD-GC-23 Rev. 10-17Section 5. EmploymentList in chronological order all employment since you were suspended, disbarred or resigned, beginning with the most recent. From To Name Street City State Zip code Position held Supervisor Type of business Reason for leaving From To Name Street City State Zip code Position held Supervisor Type of business Reason for leavingSection 6. Civil and Family Proceedings No YesHas a civil judgment ever been entered against you? If yes, provide the following information and a copy of the judgment and proof of satisfaction. Case name Docket number Location/Forum Amount of judgment Date satisfied Case name Docket number Location/Forum Amount of judgment Date satisfied No YesAre you presently, or have you ever been in arrears, or in default on, any court-approved agreement, judgment or court-ordered alimony or child support? No YesAre you currently a party to any pending civil proceedings, including, but not limited to, suits in equity, actions at law, suits or petitions in bankruptcy, statutory proceedings, competency or commitment proceedings, divorce, civil restraining orders, guardianship, probate, paternity, or any other civil and administrative proceeding in Connecticut or any other jurisdictions? If yes, provide the following information: Title of case Docket number Name of forum Date filed Your position in case (e.g. plaintiff) Nature of case Current status or disposition Your attorney Opposing attorney Title of case Docket number Name of forum Date filed Your position in case (e.g. plaintiff) Nature of case Current status or disposition Your attorney Opposing attorney American LegalNet, Inc. www.FormsWorkFlow.com (Page 4 of 6)JD-GC-23 Rev. 10-17Section 6. Civil and Family Proceedings (Continued) No YesHave you, or a representative, ever settled a legal malpractice claim brought against you? If yes, provide the following information: Name of client Settlement amount Date of settlement Name of client Settlement amount Date of settlementSection 7. Criminal And Motor Vehicle Proceedings No YesHave you ever been charged with a crime? (Include pending matters and dispositions resulting in convictions, pretrial diversionary programs, protective and restraining orders, nolles and dismissals). If yes, provide the following information: Title of case Docket number Name of forum Status Disposition Initial charge (if different) Conviction offense Date of disposition No YesWithin the last five years, have you been charged with reckless driving, evading responsibility, driving under the influence (DUI) or driving while intoxicated (DWI)? If yes, provide the following information: Title of case Docket number Name of forum Status Disposition Initial charge (if different) Conviction offense Date of dispositionSection 8. Current Fitness To Practice Law And Good Moral Character No YesHave you taken any continuing legal education (CLE) courses since you were disciplined? If yes, provide a copy of each CLE certificate you have received.What areas of law did you practice in before you were disciplined? What areas of law do you intend to practice