Application Form For Membership On The Criminal Justice Act Misdemeanor Panel

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APPLICATION FOR MEMBERSHIP
ON THE CRIMINAL JUSTICE ACT MISDEMEANOR PANEL
FOR THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF MARYLAND
The following 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 District of Maryland in misdemeanor cases. The Application is to be printed or
typed.*
1. NAME
_____________________________________________________________________________________
Office Address:
_____________________________________________________________________________________
City/County
_______________________________State: _____________________Zip Code: ___________________
Office Phone:
_____________________________________________________________________________________
Cell Phone/ E-Mail
_____________________________________________________________________________________
Maryland U. S. District Court Bar No. _______________________________________________________________________
Social Security No. ________________________________________________________________________________________
* The CJA payment system REQUIRES a Social Security No. for all attorneys for identification purposes. The number will
not appear on your voucher and will remain confidential.
INCOME MUST BE CREDITED TO:
Social Security No. ________________________ - OR - Employer Identification No. _______________________________
please provide
2. EDUCATION AND BAR ADMISSIONS:
Graduated from ___________________________________________ Law School on: _________________________________
Admitted to practice in (please list jurisdiction of first admission) _________________________________________________
on __________________________________________.
Admitted to practice in the United States District Court for the District of Maryland on ______________________________
Admitted to practice in the United States Court of Appeals for the Fourth Circuit on ________________________________
3. DISCIPLINARY ACTIONS:
Have you ever been disciplined (or are you the subject of any pending disciplinary action) by the Bar of any jurisdiction or by any
Court? _________ If so, please explain 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.
4. Please indicate whether you have any special qualifications, such as fluency in a foreign language, which you believe the Selection
Committee should be aware of in reviewing your application.
________________________________________________________________________________________________________
_________________________________________________________________________________________________________
5. Please list prior trial experience in federal or state court:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
6. Judicial Clerkship: No________
Yes_______________

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