Position(S) Ofunited States Bankruptcyjudge

APPLICATION FOR

POSITION(S) OFUNITED STATES BANKRUPTCYJUDGE

Instructions:

Allquestionsmustbe answered.Ifaquestionor sectionisnotapplicable,pleasesostate.Pleaserespondfully,usingadditionalpagesifnecessary,givingfullnamesandcurrentofficeaddressesand phonenumbers (orresidence, ifnooffice) foralljudicial,professional,personalorotherreferences.Pleaseprovideanoriginalandsevencopiesofyourcompletedapplicationandonecopyeach of five writingsamples - all documents should be unbound, single-sided,either clippedor stapled.Submit a pdf of eachdocument provided on aCD or flash drive.

AllinquiriesshouldbedirectedtotheCircuitExecutive,CollinsT.Fitzpatrick,United States CourtofAppealsfortheSeventhCircuit,219SouthDearbornStreet,Room2780,Chicago,Illinois60604. Completed applicationsshouldbe senttothe CircuitExecutive. The envelope shouldbemarked in the lower right-handcorner“BankruptcyJudgeApplication.”

Yoursignatureinthelowerright-handcornerofthisdocumentindicatesyourconsenttothisevaluation and the checkingof references.

Applications areto be received on or beforeJune 20, 2016.

Signature of Applicant

OfficePhone:ResidencePhone: Email Address:

Date Signed:

PART A --PERSONALBACKGROUND

1. / (a) / Full Name:
(b) / Other names bywhich known:
/ (c) / Address: Office Residence

Phone Residence

Phone

(d)Residenceaddresses, past five (5)years, with dates:

(e) / Birth: DatePlace
(f) / Marital Status
Spouse's Name
(g) / Children:NumberAges
2. / (a) / Have youserved in the U.S. or other military?
(b) / ServiceDates
3. / (a) / Haveyoueverbeenconvictedofafelonyoramisdemeanor(excludingminortraffic

offenses)?

(b)If so, state the factsandcircumstancesfully, including date,court,and disposition.Use separateattachment form.

PART B -- EDUCATIONALBACKGROUND

4. / (a) / High SchoolGraduation Date
(b) / College: Includenon-legalgraduate work.

SCHOOLDATESMAJORDEGREE

(c)Honors, Awards, etc.

5.Describeanyother formaleducation or courses (omitting primaryand legal).

6.Legal: Includeall law schools attended.

(a)SCHOOLDATESDEGREE

(b)State in detail anyhonors, awards, law review,otheractivities or achievements.

PART C --PROFESSIONAL AND OCCUPATIONALBACKGROUND

7.(a)When were you admitted to practice in/?

(State)(Year)

(b)How longhave youpracticed in/?

(State)

(c)Nameallstates,courtsandadministrativeagenciesortribunalsbeforewhichyouhavebeenadmittedtopractice,datesadmitted;statewhetheryouarecurrentlyadmittedandwhether you activelypracticetherenow.Donot includespecialadmission foraparticularcase.

COURT, AGENCY, ETC.DATECURRENT?ACTIVE

COURT, AGENCY, ETC.DATECURRENT?ACTIVE

8.Do you activelypractice law in anyother state? If so, describeextent and nature of practice.

9.BarAssociation and Activities.

Listallnational,state,localspecialty,honoraryandotherbarassociationsorotherlegalsocietiestowhichyouhavebelonged.Stateastoeachcommitteemembershipandotheractivity: offices held, whetheryou arenow a member in goodstanding, or if not, why.

10.Listanyjudicial or quasi-judicialofficesyou have held or applied for. Do notincludeanypresent judicial office you hold.

(Circle For P for full or part-time.)

OFFICELOCATION

FP FP

PERIOD

OF SERVICE orDATE OFAPPLICATION

11.List anyelective public office you have everheld (other than judicial or quasi-judicial).

PERIOD

OFFICELOCATION

OF SERVICE

12.List anyappointive public officeyou have everheld (other than judicial or quasi-judicial).(Circle For P for full or part-time.)

FPOFFICE:DUTIES: LOCATION:

F POFFICE:DUTIES: LOCATION:

FPOFFICE:DUTIES: LOCATION:

13.List anyelective public officefor whichyou have been an unsuccessfulcandidate.

OFFICELOCATIONDATE

14.Present professionalpractice oroccupational status, whether law-related or not.

Describeyour title, position, your dutiesor type ofpractice, inceptiondate, and list namesandcurrentphonenumbersofpartners,associates,orpersonswithwhomyoushareanoffice.

(a)Title/Position

(b)Practice/Occupation

(c)Partners/Associates/etc.

15.Past legal or law-relatedprofessional status.

(a)Giveabriefhistoryofyourlegalcareerin inversechronologicalorder.Beginwiththe most recent experienceprior to yourpresent status.

PERIOD

ByYears

19-

PLACE

City,County,State

STATUS

Solo Practice,partner,assoc., officesharer

TYPE OF PRACTICE

Probate, generalinsuranceclaims, etc.

(b)Astoyourpastpracticeasstatedin(a)above,listthenamesandcurrentofficephonenumbers of partners,officesharers, etc., for the sameperiods as stated in (a) above.

PERIOD

ByYears

19-

NAME OFLAWYER

STATUS OF LAWYER

Partner, assoc.,office

sharer,etc.PHONE

16.Indicatethepercentageoftimedevotedtodifferenttypesofpractice,anddescribeyourtrial(juryand non-jury) and appellateexperience.

17.Non Law-Related. Professional and OccupationalBackground.

(a)Listallprofessionalor occupational licenses(other thanlaw) whichyouhave everheld.If licenseis still current, so indicate bychecking"C".

LICENSEISSUINGAUTHORITYDATEC

LICENSEISSUINGAUTHORITYDATEC

(cont.)

(b)Ifanysuchlicensehaseverbeenrevokedorsuspendedor if yourconducthasbeenthesubjectofotherdisciplineorcomplainttothelicensingauthorityoritsdisciplinarybody,state fullythe facts and circumstances and the disposition. Use separateattachmentform.

(c)Describefullyallnon-law-relatedprofessionsoroccupationspursuedsinceyourfirstadmission to the bar, givingdates, companynames, duties, reasonsleaving, etc.

PART D --PROFESSIONAL AND PERSONAL CONDUCT

YOUR NAME

18.(a)Hasyourlicenseorrighttopracticebeforeorinanystate,court,agency,orothertribunaleverbeendenied,revoked,orsuspended? Ifso,statethefactsandcircumstancesfully. Use separateattachment form.

(b)Have youeverbeen formallycensured,adjudged orheld incontempt orotherwisedisciplined byanyjudge, court, agency, or tribunal? Ifso,state the factsand circumstancesfully. Use separateattachment form.

(c)Hasyourprofessionalconductorabilitybeen thesubject of comment,favorableorunfavorable,inawrittenopinionofanyjudge,court,orothertribunal? Ifso,attachacopyoftheopinionandstatefactsandcircumstancesyoufeelappropriate.Use separateattachment form.

19.(a)Haveyoubeenthesubjectofanycomplaintfiledwithormadetoanyboardofattorneysforprofessionalresponsibility? Ifthecomplaintwasdismissedwithnoactiontakenagainstyou,thatisallyouneedsay.Ifanyaction,includingawarning,wastaken,please state fullythe factsand circumstancesand thedispositionof the matter.Use separateattachment form.

(b)Haveyoubeenthesubjectofanycomplaintfiledwithormadetoanysimilarauthorityof anyother court or state? Ifso,statefullythefactsandcircumstancesand the disposition of the matter. Use separateattachment form.

20.Have you everbeen thesubject of acomplaint filedwith ormadeto anybar association orcommittee thereof? Ifso,statefullythefactsand circumstances and thedisposition of the matter. Use separateattachment form.

21.Haveyoueversuedorbeensuedbya client?.If so, state fullythe facts andcircumstances;thecourtandcasenumber;names,addresses,andphonenumbersofyourattorneyandallothercounsel;andthedispositionofthematter. Useseparateattachmentform.

22.Haveyoueverbeenapartytoorotherwisepersonallyinvolved(otherthanascounsel)inanylitigation? Ifso,statethecourt,casenumberandstyle,thenatureofthe caseand the circumstances of your involvement, the namesand current phonenumbers of yourattorneyand ofanyattorneyrepresentingan interestadversetoyours, andthe disposition.Use separateattachment form.

23.Hasataxlienorothercollectionprocedureeverbeeninstitutedagainstyoubyfederal,state,or local authorities? If so, giveparticulars. Useseparateattachmentform.

NOTE:Allcandidatesmustcompleteandsignandreturntheattachedauthorizationforms relating to disciplinary and grievance matters.

PART E -- PERSONAL AND JUDICIAL REFERENCES

YOUR NAME:

24.(a)Givethenamesandcurrentphonenumbersofatleastfive,butnomorethantenpersons(ofwhomnotfewerthanfourmustbelawyersnotassociatedwithyouinthepracticeoflaworinbusiness)towhomyoureferastoyourcharacterandability,andstatehowlongeachhasknownyou.Yourreferencesmusthavehadadequateopportunitiesforobservingyourprofessionalandgeneralconductandability.Describethestatusofnon-lawreferences.

PERIOD OF

NAMEPHONE NUMBER

ACQUAINTANCE

(b)Givethenamesandcurrentphonenumbersofatleastthreepersonswhohaveworkedfor you and with you in a subordinate position.

NAMEPHONE NUMBERWORK RELATIONSHIP

NAMEPHONE NUMBERWORK RELATIONSHIP

(c)Givethenamesandcurrentphonenumbersofnotmorefivejudges(ofwhomatleastthreemustbeactive)withwhomyouarenotandhavenotbeenassociatedinthepracticeoflaworinbusiness,beforewhoyouhaveappearedrecentlyinmatterswhichwouldaffordthemanopportunitytoobserveyourprofessionalconductandability.Ifyoursisanon-litigationpractice,listsuchjudges,ifany,whohavehadanopportunitytoobserveyouinbarassociation or otheractivities. Ifyou area judge, list judges familiar with your work.

NAME OFJUDGECOURT

DATE ANDNATURE

OF MOST RECENT CASEDATE

PART F-- ADVERSARYREFERENCES

YOUR NAME:

25.This question asksforthenamesandcurrentphonenumbersoflawyerswhohaverepresentedadversepositionsinmattershandledbyyouinthepasttwoyears.Therearetwocategories,litigationandnon-litigation.Eachcategoryhasspaceforthelistingofthenamesoftwentylawyers.Donotlistthenameofalawyermorethanonceineithercategory.Ifyouhavehadmultiplematterswithalistedlawyer,indicatethefactby(M)followinghisorhername.Insuchinstance,byseparateattachment,listnomorethanfiveadditionalmattersorcases with dates as to eachlawyer.

Ifyouhavelistednamesoftwentylawyersinacategory,youneednotanswertheothercategory;butifyoudo,listnomorethantennamesin thatothercategory.Applicantswhoarejudges need to list names of twentylawyers whohave appearedbeforethem in the lastyearin adversarialmatters.

(a)LitigationMatters:

NAME OFLAWYERCOURT

NUMBER AND

CASE STYLEDATE

(b)Non-litigation Matters:

NAME OFLAWYERPHONENATURE OFMATTERDATE

PART G-- WRITTEN WORK

26.(a)Pleaseattachfiverepresentationalsamplesofyourwrittenwork(articles,opinions,treatises,trial,orappellatebriefs.)Statewhetheryouwerethesoleauthor.Ifyouwerenot,

listthenames,currentofficeaddresses,andtelephonenumbersofthepersonswhoassistedyou in the writingor research.

PART H – CONCLUSION

27.StatewhyyoubelieveyouarequalifiedtoperformthedutiesofaUnitedStatesBankruptcyJudge.Includeanyspecialprofessionaloccupational,orcivicexperienceyouhavehadthatyoubelieveshouldbeconsideredby thecommittee.Includeany legalteachingyouhavedone.

28.State anyother information which you believe to berelevant to the Committee'sreview.

NOTE: Remember to return the authorization and all attachments withyour return ofthisquestionnaire.

SEPARATE ATTACHMENT FORM

YOUR NAME

This is a separateattachment to Part, Question.

AUTHORIZATION & WAIVER

Iherebyauthorizetheadministratorsofthedisciplinaryandinquirybodiesofanystate,court,orbarassociationofwhichIamamember to disclose to the Committee allinformationcontained inthefilesofsuchbodiesconcerningmypresentprofessionalstatus,allcomplaintswhichhavebeenmadeagainstme,togetherwiththedispositionthereof.IexpresslywaiveforusebytheCommittee,theSeventhCircuitJudicialCouncil,andtheUnitedStatesCourtofAppealsfortheSeventhCircuitwhateverright Imayhave to confidentialityof the foregoinginformation.

(Print or typename)(Signature)

(Address)

(DateSigned)