Questionnaire And Application For Membership In Criminal Justice Act Panel

<document>COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.QUESTIONNAIRE AND APPLICATION FOR MEMBERSHIP IN THE CRIMINAL JUSTICE ACT PANEL FOR THE UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF FLORIDAJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .The following Questionnaire and Application is to be completed by attorneys requesting to represent defendants under the provisions of the Criminal Justice Act in the United States District Court for the Middle District of Florida:THE APPLICANT IS HEREWITH APPLYING FOR APPOINTMENT AS A CJA PANEL ATTORNEY.1.Name:Firm Name: Office Address:THE PEOPLE OF THE STATE OF NEW YORK TOGREETINGS:E-Mail Address: Office Phone: Fax Number: Home Phone:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room2.Education and Bar Admissions: Graduated fromYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.School of Law.Year:Admitted to practice in the State of Florida on: Admitted to practice in the United States District Court for the Middle District of Florida on: Admitted to practice in the United States Court of Appeals for the Eleventh Circuit on: Admitted to practice in the United States Supreme Court on:, one of the Justices of theCourt in Witness, Honorableday of, 20 County,(Attorney must sign above and type name below)Attorney(s) forOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:Application for Membership in Criminal Justice ActMiddle District of Florida Revised: February 2003Page 1 of 7Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.Others:Jurisdiction or CourtJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)LocationDate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Have you attended a continuing legal education seminar on the topic of the Federal Sentencing Guidelines, and their application, within the twelve months prior to this application? If so, have you certified your compliance with this requirement with the Federal Public Defender?THE PEOPLE OF THE STATE OF NEW YORK TOYes No GREETINGS:Have you attended and completed a continuing legal education seminar on federal court criminal practice within the twelve months prior to this application? If so, have you certified your compliance with this requirement with the Federal Public Defender?WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofYes No o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Alternatively, have you reviewed the video presentation concerning criminal practice in the Middle District of Florida (which is on file in the Federal Public Defender Office in each division of this District) within the twelve months prior to this application?, one of the Justices of theYes No Court in Witness, Honorableday of, 20 County,Have you participated as counsel of record, either as prosecutor or defense attorney, in at least one criminal jury trial in any federal court?(Attorney must sign above and type name below)Yes NoIf not, have you participated in the District's second chair counsel program? If so, please attach to this application a letter from the member of the division's CJA Mentor Panel verifying that you have completed the program.Attorney(s) forYes NoOffice and P.O. AddressAre you Board Certified in any area of law?Telephone No.: Facsimile No.: E-Mail Address:Application for Membership in Criminal Justice ActMiddle District of Florida Revised: February 2003Page 2 of 7Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comCOURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.Yes No JUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)If so, in what state(s) are you Board certified?If so, are you Board Certified in (check appropriate box): Criminal TrialAppellate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Civil TrialOther3.Disciplinary Actions: Have you ever been disciplined by a court or by The Florida Bar or any other state agency regulating attorneys?THE PEOPLE OF THE STATE OF NEW YORK TONoYes Are you the subject of any pending disciplinary action by the Bar of any jurisdiction or by any Court?GREETINGS:NoYes WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,If so, please explain in detail on a separate sheet of paper bearing your name and address what the discipline was and the nature of the conduct that led to the disciplinary action.located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room4.Practice Background (give dates by years): Served as federal defender Served as state defender Served as federal prosecutor Served as state prosecutor Served in private practice Served as a Law Clerk Other: (please describe)Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., o