APPLICATIONFORM

UNITEDSTATESMAGISTRATEJUDGE

Please submit a disk in Word or pdf file via e-mail to , andeight (8) paper copies of your application with the Clerk of Court at 225 Cadman Plaza East, Brooklyn, NY 11201.

ThisformwillbekeptconfidentialandwillbeexaminedonlybymembersoftheMeritSelectionPanelandthejudgesofthedistrictcourt.Beadvisedthatcolleagues,formeremployers,andtheindividualsyouhavelistedasreferencesinthisapplicationmaybecontactedwithout your priorapproval.Wewill seekyour approval prior to contactingyourcurrentemployer. SeeWaiver of Confidentiality attached.

General:

1. / FullName:
2. / Allother namesbywhichyou havebeen known:
3. / OfficeAddress:
CityState / Zip Code

Telephone Number:E-MailAddress:

4.AllCurrentResidentialAddresses:

Telephone Number(s):

5.Time atcurrentresidence(s):Time of residence in state:

6.Place ofBirth:Date ofBirth:

7.Ifyou area naturalized citizen, please state thedate and placeof naturalization:

8.MilitaryDuty:Service:Branch:Dates:

Rank or rateat discharge:Type of discharge:

IfstillaReserveorNationalGuardmember,pleasegiveservice,branch,unitandpresentrank.

9.Areyourelated bybloodormarriagetoanyjudgesofthiscourtortoanymembersofthe

MeritSelectionPanelwhowillreviewthisapplication? Yesnames.

Health:

No. Ifso,givetheir

10.What is the presentstateofyour health?

11.DoyouhaveanyvisualorhearingimpairmentorothermentalorphysicalimpairmentthatwouldrequireaccommodationbytheCourttopermityoutoperformthedutiesassignedtoamagistratejudge?Ifso,specify.(BeassuredthattheCourtdoesnotdiscriminate andwill provide reasonable accommodation for anyhandicap.)

12.Haveyouhadanyhospitalconfinement,mentalillness,seriousphysicalillness,ordrugoralcoholaddictionduringthepastten(10)years? Yes No .Ifyes,explainandprovidethename,addressandtelephonenumberofyourattendingphysician(s),andallhospitalsandotherinstitutionstowhichyouwereadmittedandthedate(s)ofeachhospitalization.

13.Areyoupresentlyreceiving orcontemplating receiving treatmentforaphysicalormentalillnessorcondition,orfordrugoralcoholaddiction? Yes No .Ifso,pleasegivedetails.

Education:

14.Collegesanduniversities(includingprofessionalschools)attended:addresses,datesanddegree(s):

15.Haveyoumet,anddoyoucurrentlymeet,theContinuingLegalEducationrequirementsof each jurisdiction in whichyou havebeen amemberofthebar?

Ifnot, pleaseexplain:

Honors:

16.Wereyouamemberofanylawreview?

NamesPositionsDates

17.Ifyouhave publishedanylegal books or articles,list them,givingcitationsanddates:

18.Listanyother honors, prizes or awardsyou have received:

ProfessionalAdmissions:

19.Listallcourts(includingstatebaradmissions)andadministrativebodieshavingspecialadmissionrequirementsinwhichyouarepresentlyadmittedtopractice,givingthedatesof admission in each case:

Court or Administrative BodyDateof AdmissionI.D.Number

LawPractice:

20.Commencingwithyour law schooladmission,state thenames, positions, dates,addressesandtelephonenumbersofalllawfirmswithwhichinanywayyouhavebeenemployedorassociatedinpractice,andofallgovernmentalagenciesorprivatebusinessorganizationsinwhichyouhaveeverbeenemployedorassociated,periodsduringwhichandaddressesfrom whichyouhavepracticedas asole practitioner,andanylegal practiceor employment not otherwise coveredbyyouranswers.

21.Describethegeneralnatureofyourcurrentpractice,includinganylegalspecialtieswhichyoupossessandthecharacterofyourtypicalclients.Additionally,ifyourpracticeissubstantiallydifferent now from what it previouslyhad been, pleasegive complete detailsof prior practice.

22.(a)Doyouappear regularlyin court?

(b)Whatwouldyouestimatetobethepercentageofyourcourtappearancesinthelastfive (5) were in:

1. / federalcourts / %
2. / stateor local courts of record / %
3. / administrative bodies / %
4. / other (be specific) / %

23.Duringthe lastfive (5)years, what percentage of your practice has been litigation?

%

24.Duringthe lastfive (5)years, howfrequentlyonaverage haveyouappeared in court?

timesper month

25.List the percentage ofyour practice involvinglitigationwhichhasbeen:Civil%

Criminal%

Other%

26.(a)Listyourcases which havegoneto trial incourtsof recordduringthepastfive (5)years,indicatingwhetheryouweresole,associate,orchiefcounsel.Givethedocketorindexnumberofeachsuchcaseandgivethecitationsofanyreportedopinions.Ifasubstantive opinion is unreported, pleaseprovideacopyof anysuch opinion. Provide thenameandcontactinformationofeachchiefcounselrepresentinganyparty atthetrial,thenameofjudgewhopresidedoverthetrialand(i)whetherthetrialwenttoverdictordecision or (ii) whether the trialbegan, but terminated,before conclusion.

(b)Listanyappealsyouhavehandledinafederalorstateappellatecourtinthepastfive(5)years,indicatingwhetheryouwerethesole,associateorchiefappellateattorney.Identify theappellatecourtandgivetheappealnumberofeachappealandthecitationofanyopinion.Ifasubstantiveopinionisunreported,pleaseprovideacopyofanysuchopinion.Providethenameandcontactinformationofeachattorneywhoarguedtheappeal foranypartyandindicate the action takenbytheappellate court.

27.Summarizeyourcourtroom experience for thelast five (5)years:

28.Otherthanthecaseslistedinresponsetoquestion26,listthecasesyouhavelitigatedoverthelastthree(3)yearsandprovidethecontactinformationofchiefcounselrepresentinganyparty appearing inthecase,thecourtinwhichthecasewaslitigated,thedocket or indexnumbersandanycitations ofthecases.

Feelfreetolistanycasesthatyoumayhavelitigatedmorethanthree(3)yearsagothatyouwish to drawto the Panel’sattention.

PublicOffice:

29.Haveyoueverrunfor,orheld,publicoffice?YesNo. Ifso,give details.

Prior JudicialExperience:

30.(a)Haveyou ever held judicial office orbeena candidate for judicialoffice?

YesNo. Ifso,pleasestatethecourtsinvolvedandthedatesofservice,ordates of candidacy.

(b)Prior quasi-judicialservice:Name of agency:

Position held:

Hearingon what issues:Number of casesadjudicated:Dates of service:

(c)List each District Court in which you have applied to be appointed a United States Magistrate Judge and the year(s) you applied.

BusinessInvolvement:

  1. Ifyouarenowanofficer,directororotherwiseengagedinthemanagementofanybusiness enterprise, state the name of such enterprise, the nature of thebusiness, thenatureofyour position andofyourduties, andwhetheryou intend toresign such position immediatelyuponyourappointment to judicialoffice.
  1. SincebeingadmittedtotheBar,haveyoueverengagedinanyoccupation,business,orprofessionotherthanthepracticeoflaw? Yes No .Ifso,givethe details,includingdates.
  1. Statewhetherduringthepastfive(5)yearsyouhavereceivedanyfeesorcompensation ofanykind other than for legal services renderedfromanybusinessenterprise,institution,organizationorassociationofanykind. Yes No .Ifso,identify thesourceofthebusinessenterprise,institution,organizationorassociationinvolved,andthe datessuch compensation waspaid.
  1. (a) Haveyoueverbeenarrested,charged,orconvictedforviolationofanyfederallaw,statelaw,county ormunicipallaw,regulationorordinance? Yes No .Ifso,givedetails.Donotincludetrafficviolationsforwhichafineof$200orlesswasimposedunless it alsoincluded a jailsentence.
  1. Haveyou,toyourknowledge,foranyreasoneverbeenunderfederal,stateorlocalinvestigation?Yes ___No ___. Ifso,give particulars.
  1. (a)Haveyoueverbeensued byaclientfor anyreason,includingprofessionalmalpractice?Yes No . Ifso,give particulars.
  1. Haveyouoryourprofessionalliabilityinsurancecarriereversettledaclaimagainstyouforprofessionalmalpractice? Yes No .Ifso,giveparticulars,includingthe amounts involved.
  1. Haveyoueverbeeninvolvedasapartytoanylitigation(criminal,civiloradministrative)? Yes No . Ifso,give particulars.
  1. (a)Haveyoueverbeendisciplined,cited,admonishedorcautionedforabreachofethicsorunprofessionalconductbyanycourt,administrativeagency,barassociation,orotherprofessionalgroupor,withoutregardtotheoutcome,toyourknowledge,hasthereeverbeenacomplaintpreferredagainstyouwithorbyanycourt,administrativeagency,barassociationorotherprofessionalgroup? Yes No . Ifso,give the particulars.
  1. Haveyoueverbeenquestionedbyanyprivateorpublicentityconcerninganypossiblemisconduct,incompetence,unsatisfactoryperformanceofdutyorviolationoflaw?Yes No . Ifyes,give particulars.
  1. Toyourknowledge,haveyoueverbeenthesubjectofaninvestigationbyanypersonorprivateorpublicentityconcerninganypossiblemisconduct,incompetence,unsatisfactoryperformanceofduty,orviolationoflaw? Yes___No____. Ifyes,give particulars.
  1. Haveyou, toyourknowledge, everbeen found not qualifiedfor anypublicpositionbyanycourt,administrativeagency,barassociationorotherprofessionalgroup?Yes ___No ___. Ifyes,give particulars.
  1. Haveyoueverbeendisciplinedorterminatedbyorbecauseofpossibleterminationresignedfromanypublicorprivateemployer,lawfirmoranyotherentitybecauseofanymisconduct,incompetenceorunsatisfactoryperformanceinanyrespect?Yes___No __. Ifyes,give particulars.
  1. Haveyoueverresignedfromor,forotherreasons,ceasedtobeamemberofthebarorbenchofanystateorcourtinanyjurisdiction,amemberofanygovernmentalbody,ahearingofficeroranoccupantofanyothersimilarposition?Yes No____. Ifso,give particulars.
  1. HaveyoufiledappropriatetaxreturnsasrequiredbyFederal,State,Local,andotherGovernmentauthoritiesinatimelyfashion?Yes No . Ifno, explain.
  1. (a)HaveanyliensorclaimseverbeeninstitutedagainstyoubytheFederal,Stateorlocalauthorities?Yes No . Ifyes,explain.
  1. Doyouhaveanysummonses,trafficticketsorothersuchclaimsoutstandingagainstyoubyanyfederal,stateorlocalauthorities?Yes___ No____. Ifyes,giveparticulars.
  1. Arethereanyunsatisfiedjudgmentsagainstyou? YesNo.Ifyes,giveparticulars.
  1. Areyouindefaultintheperformanceordischargeofanydutyorobligationimposeduponyoubyanygovernmentalagencyordecreeororderofanycourt,includingalimony/maintenanceandsupportordersanddecrees? Yes ____ No ___.Ifyes,give particulars.
  1. Haveyouevermadeanassignmentforthebenefitofcreditors? Yes___ No_____.Ifyes,give particulars.
  1. Hasanypetition in bankruptcyever been filedbyor againstyou?YesNo. Ifyes,give particulars.

Professional and OtherActivities

  1. (a)Listallbarassociationsandlegal professional societies of which you are amemberandgivethetitlesanddatesof any officeyouhaveheldorcurrentlyholdin suchgroups,andcommittees to whichyoubelongedorcurrentlybelong:
  1. Listallorganizations and clubs,otherthanbarassociationsand professionalsocietiesidentified in responseto Question37(a)ofwhichyouhavebeen amemberduring thepastten(10)years,including thetitlesanddatesofanyofficesyou have held in each such organization:

SupplementalInformation

  1. State any achievements or actions you have accomplished, demonstrating yourcommitment to equaljustice under law:
  1. Stateanyadditionaleducationorotherexperiencesyoubelievewouldassistyouinholdingjudicialoffice:
  1. Listfive(5)individualsasreferenceswhoarefamiliarwithyourabilitiesandpersonalcharacter:

NameAddressTelephone Number

  1. (a) Setforthanyinformationnototherwiseelicitedbythisapplicationwhichwouldaffect,favorably orunfavorably,youreligibility fortheofficeforwhichyouareacandidate orbearupon consideration ofyour candidacy:
  1. Isthereanythinginyourpersonalorprofessionalbackgroundthat,ifpubliclyknown,could be viewedasembarrassingeither toyou personallyorto this court?Yes No . Ifyes,give particulars.

Thisapplication is for the UnitedStatesMagistrate Judge position at:

☐Brooklyn☐ CentralIslip☐EitherCourtLocation

(Please checkonebox)

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IdeclareunderpenaltyofperjurythatIcompletedtheforegoingfourteen(14)-pageapplicationwith the attachments,andthat it containstrue andcorrectinformation.

Executed on:

Date:

Signature of Candidate:

ConfidentialityStatement

Theindividualswhomyouhavelistedasreferencesin#40above maybecontacted bythePanel,butnootheremployers,colleaguesorotherswillbecontactedwithoutyourpriorapproval.The “Waiver of Confidentiality” will not be usedwithoutyourprior approval.

How To Apply

Theoriginalplustherequiredcopiesofthecompleteapplication(withallappendices)mustbereceivedbyClerkofCourt,225CadmanPlazaEast,Brooklyn,NewYork11201,notlater than thedate specified in thePublic Notice.

Youare invited to append:

1.A one-page curriculumvitae.

2.A one-page statement on what you believe you bring to the position of U.S. Magistrate Judge that is not immediately apparent from your application and curriculum vitae.

N.B. Ifyouchangeyouraddressorifanythingoccurswhichwouldaffectyouranswerstothisapplication,notice ofsuch change should besent to the Chairman oftheMerit SelectionPanel.

WAIVER OFCONFIDENTIALITY

TheMeritSelectionPanelmaybeinneedofadditionalinformationonyourbackgroundandqualificationstodeterminewhethertorecommendyoutotheDistrictCourtforappointmentasaMagistrateJudge.Accordingly,werequestyourapprovaltoconsultwithyourpastemployers,colleagues,referenceslistedbyyouandotherindividualswhohavematerialknowledgeofyourqualificationsinordertoverifyandtosupplementtheinformationcontainedinyourapplicationform.A“waiverofconfidentiality”isprintedimmediatelybelowforthispurpose.

Wewillnotcontactyouremployerunlessyougiveusspecificpermissioninaseparatedocument.

Waiver

Iherebyauthorizethecustodianofanyrecordsorinformationtopermittheexaminationorreceiptofsuchinformation,whetherwrittenororal,bytheMeritSelectionPanel.IalsoauthorizetheMeritSelectionPaneltoconsultwithmyformeremployers,myprofessionalcolleagues,referenceslistedbyyouandotherindividualswhohavematerialknowledgeofyourqualificationswithregardtomatterspertinenttomyqualificationsforthepositionofaUnitedStatesMagistrate Judge.

Date:

Signature: