Form 11 - Connecticut Bar Examining Committee Page 2

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Form 11

JULY 16

Connecticut Bar Examining Committee

(Name & Address of Employer)

Applicant:

Name during employment (if different):

SSN:

Name of Employer/Company:

Position Held:

Dates of employment:

From:

To:

This applicant has filed for admission to the practice of law in Connecticut. We are conducting a routine investigation into his/her character and fitness to

become an attorney. We would appreciate your candid evaluation of the applicant. Please complete this form in its entirety. A personal letter will not be

accepted in lieu of this form; however, a personal letter may be attached hereto. This form has been sent to you by the applicant pursuant to the Bar

Examining Committee’s directions. It must not be sent back to the applicant, but sent directly to the Committee. The applicant was instructed to enclose a

prepaid envelope addressed to the Committee. Thank you for your time. The Committee must receive this completed form by September 5, 2016.

1. How long have you known the applicant? __________________________

2. Are you related to the applicant? ____ If so, in what way___________________________

3. What position did the applicant hold in your office? _______________________________

4. What were the applicant’s dates of employment? From: ____________ To: _____________

5. Were you satisfied with the applicant’s performance of his/her duties? ___________ . If not, please tell

us why on the other side.

6. To your knowledge:

YES NO

[ ]

[ ] Has the applicant been arrested within the past five years or ever been convicted of a crime

[ ]

[ ] Has the applicant ever been accused of a violation of trust

[ ]

[ ] Has the applicant ever been dropped, suspended from, disciplined or placed on probation by

an educational institution

[ ]

[ ] Has the applicant ever been a party to a law suit (including bankruptcy)

[ ]

[ ] Has the applicant ever been denied admission to the bar of any jurisdiction

[ ]

[ ] Has the applicant ever been delinquent in any financial obligation

[ ]

[ ] Does the applicant have any condition or impairment which in any way currently affects the

applicant’s ability to practice law

[ ]

[ ] Has the applicant ever exhibited any pattern of behavior or conduct that raises significant

concerns about the applicant’s character and fitness to practice law

If you answered "yes" to any of these questions, please tell us about it. You may also use this space for any

additional comments you wish to make about the applicant.____________________________________

_____________________________________________________________________________

7. To your knowledge is the applicant currently suffering from a disability which would impair the applicant's

ability to practice law?_____ If so, explain. ______________________________________________

_____________________________________________________________________________

________________________________

_______________________________

Print Name

Signature

Sworn to before me this

_____ day of __________, 20___.

_______________________

Notary Public

Please note: Any information that you provide will be held in confidence unless it is used to establish probable cause to deny the applicant's admission to the bar.

Return address:

CT Bar Examining Committee

July 2016 Bar Examination

Reference Letter Department

100 Washington Street

Hartford, CT 06106-4411