Court Appointed Counsel List Form

ELEVENTH DISTRICT COURT OF APPEALS COURT APPOINTED COUNSEL LIST FORM Please include my name on the Court Appointed Counsel List for the Eleventh District Court of Appeals. I am in substantial compliance with the requirements of OAC Chapter 120-1 and will accept appointments in the following areas: Criminal Juvenile Termination of Parental Rights NAME___________________________________________________________________ SUPREME COURT REGISTRATION NO. ____________________________________ ADDRESS________________________________________________________________ TELEPHONE NO. _____________________ FAX NO. __________________________ E-MAIL ADDRESS: PREFERRED COUNTIES: ____Ashtabula ____Geauga _____Lake CERTIFICATION: ____Portage ____Trumbull I certify that I have reviewed Ohio Administrative Code 120-1-10, and I will accept appointments as provided by this section. I further agree to inform the Court if and when I am no longer in substantial compliance with OAC 120-1-10 for any category of appointments. I understand the court may require me to renew this certification periodically in order to remain eligible for court assignments. (http://codes.ohio.gov/oac/120-1-10v1). ________________________________________ Attorney (Print Name) _________________________________________ Signature Please email the completed copy of this form to: lcireland@11thappealohio.us, or mail to her at: Linda C. Ireland, Court Paralegal Eleventh District Court of Appeals 111 High Street, N.E. Warren, Ohio, 44481 Or return by fax: 330-675-2655. American LegalNet, Inc. www.FormsWorkFlow.com _________________________ Date