Application For District 15B Indigent Lists {PD-EA2}

Application for District 15B Indigent Lists NC Bar No. Name Firm Name Office Address ***Office must be physically located in District 15B*** Telephone Fax Email Licensed to practice in North Carolina (month/year) Licensed to practice in other jurisdictions (month/year) Please indicate below the list(s) you request to be placed on. Refer to Article IX for list description and requirements. [List 5 is currently not available]. List 1: Misdemeanor n/a List 5: Involuntary Commitment List 2: G through I felonies List 6: Child Support List 3: A through F felonies List 7: Parent Representation List 4: Juvenile List 8: Special Proceedings Counsel I request placement on the above list(s) for Orange Chatham Both List briefly your trial experience, included specialized CLE: Please list 2-3 attorney references: Please indicate any additional information that will facilitate the decision regarding your placement on the list(s). You may attach additional information that you desire to be considered. At the discretion of the Indigent Defense Committee, attorneys are subject to an annual review to ensure quality representation and compliance with the 15B Judicial District Regulations for Appointment of Counsel in Indigent Cases. ____________________________ DATE SIGNATURE Updated: 6/7/2004 PD-EA2 Office of the Public Defender