APPLICATION FORM FEDERAL PUBLIC DEFENDER

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APPLICATION FORM

FEDERAL PUBLIC DEFENDER

If you need additional space, continue under “Remarks” listing item number

General

Full Name: Present Title:

All other names by which you have been known:

Office Address:

Residential Address:

Office Phone: Mobile Phone: Email:

In what countries do you hold citizenship:

Are you related by blood or marriage to any member of the federal judiciary?

If yes, give their names and the relationship.

Yes

Name Relationship

Military Service:

(Include branch, dates of service, rank or rate at discharge. If still a reserve or national guard member, give service, branch, unit, and present rank.)

Branch Dates of Service Rank Unit

College(s) or university(ies) attended:

Institution Dates Attended Degree Class Standing

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Law schools attended:

Institution Dates Attended Degree Class Standing

Honors

List your law school honors (e.g. law review, moot court participation):

List any legal books or articles written by you, giving citations and dates:

List any honors, prizes, or awards you have received:

List the five most recent legal education courses or seminars attended, including sponsors and approximate

dates:

Course/Seminar Name Sponsor Date

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Professional Admissions

List all courts (including state bar admissions) and administrative bodies having special admission

requirements in which you are presently admitted to practice, giving the dates of admission in each case.

Court or Administrative Body Date of Admission

Professional Activities

Have you been engaged in the active practice of law for at least five years?

Yes No

State the name, dates, and addresses of all law firms with which you have been associated in practice and of all

governmental agencies or private business organizations in which you have been employed, periods you have

practiced as a sole-practitioner or worked in and list that information for any other prior practice:

Position Firm Address Dates

Describe the general nature of your current practice including any legal specialties which you possess and the

character of your typical clients. Additionally, if your practice is substantially different now than previously,

please give details of prior practice.

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Do you regularly appear in court?

Yes No

What percentage of your appearances in the last five years were in the following forums:

Federal Courts

State Superior Courts

State District Courts

State Appellate Courts

Juvenile Court

Other?

Administrative Bodies?

Which Administrative Bodies?

During the past five years, what percentage of your practice has been trial practice?

How frequently have you appeared at administrative hearings?

times per month.

What percentage of your practice involving litigation has been in each of the following areas:

Civil

Criminal

Federal Court

State Court

State the number and nature of the cases which you have tried to conclusion in courts of record during each of

the past five years, indicating whether you were sole, associate, or chief counsel. Give citation of any reported

cases.

Year # of Cases Role Citations

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State as to each case tried to conclusion (a) the date of the trial period or periods, (b) the name of the court and

the judge before whom the case was tried, and (c) the individual name and telephone number of counsel for

each of the other parties:

Case Number & Title Trial Dates Court Judge

Counsel Name and

Phone Number

State the names and addresses of adversary counsel in the three most legally significant cases you have had in

the last five years:

Name Address

Summarize your courtroom experience for the past five years:

Public Office

Have you ever run for, or held, public office? If so, give details.

Yes No

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Prior Judicial Experience

Have you ever held judicial office, been interviewed for a judgeship, or applied for a

bankruptcy judge position? If so, state the courts involved with the dates of service and/or the

date of application, and the bankruptcy judge position/s applied for.

Yes No

Court Date of Application or Dates of Service Position

Prior Quasi-judicial service:

Name of Agency Position Held Issues Heard

# of Cases

Adjudicated

Dates of

Service

Business and Other Activies

If you are now an officer, director or otherwise engaged in the management of any business or enterprise, state

the name of such enterprise, the nature of the business, the nature of your duties, and whether you intend to

resign such position immediately upon your appointment to judicial office.

Name of Business Nature of Business Duties Intent to Resign

Since being admitted to the Bar, have you ever engaged in any occupation, business, or

profession other than the practice of law? If so, please give the details, including dates.

Yes No

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Have you ever been arrested, charged or convicted for violation of any federal law, state

law, county or municipal law, regulation or ordinance? (Do not include traffic violations

for which a fine of $300 or less was imposed unless it also included a jail sentence.)

Yes No

Have you ever been sued by a client? If so, give particulars. Yes No

Have you or your professional liability insurance carrier ever settled a claim

against you for professional malpractice? If so, please give particulars, including

the amounts involved.

Yes No

Have you ever been charged in any civil or criminal proceeding with conduct

alleged to involve moral turpitude, dishonesty, and or unethical conduct? If so,

please give particulars, including the full style of the case.

Yes No

Have you ever been disciplined for a breach of ethics or unprofessional conduct by

any court, administrative agency, bar association, or other professional group? If

so, please give the particulars.

Yes No

Have you filed appropriate tax returns as required by federal, state, local, and other

government authorities? If no, please explain.

Yes No

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Do you have liens or claims outstanding against you by the Internal Revenue

Service? If so, give particulars.

Yes No

Professional and Other Activities

List all bar associations and legal or other professional societies of which you are a member and give the titles

and dates of any office you have held in such groups and committees to which you belonged.

Name Title or Committee Name Dates Served

List all organizations and clubs, other than those listed above, of which you have been a member during the

past ten years, including the titles and dates of any offices you have held in each.

Name Title Dates Served

Supplemental Information

Describe your administrative and supervisory experience. State any additional experience which you believe

would assist you in holding this position:

Please state any other pertinent information which may reflect positively or adversely on you, or which you

believe should be disclosed in connection with your possible selection as Federal Public Defender:

List five individuals as references who are familiar with your abilities and character.

Name Address Phone

State why you desire appointment to this position.

I declare under penalty of perjury that the foregoing is true and correct.

Date

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Date

Signature of Applicant

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Remarks: