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To the Appellate Division of the Supreme Court of the State of New York: The undersigned hereby applies for admission to practice as an attorney and counselor-at-law in all courts of the State of New York, and in support of such application submits the following sworn statement and the accompanying affidavits and other papers.
A. Personal Information
- State name in full: First Name Middle Name Last Name Suffix (Jr., III)
- Have you ever used or been known by any other name? No Yes If ‘Yes’, state in full each name (other than the name given above) which you have used or by which you have at any time been known, and the reason for the change, including the period of the use of such name; if change of name is by marriage so state; if change of name was by court order so state. Full Name Reason for change Full Name Reason for change
- United States Social Security number (if any):
- BOLE ID# (NYS Board of Law Examiners Identification Number): B
- State the following: Age: Date of Birth (mm/dd/yyyy): Place of Birth (City/Town/Village) State Country
- Present residence (full mailing address): Street Address City/Town/Village State ZIP Country (if not USA) Telephone E-mail (if any) Application For (check one) Admission on Examination or Admission on Motion without Examination Appellate Division (check one) 1st Dept. 2nd Dept. 3rd Dept. 4th Dept.
Pro Bono Scholars Program
Application for Admission Questionnaire - Please see the General Instructions for guidance on filing complete applications
Application for Admission to Practice as an Attorney and
Counselor-at-Law in the State of New York
New York State Supreme Court Appellate Division
Application for Admission Q uestionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
- Prior residence (provide the last permanent residence where you resided before the address in question 7): Period From (mm/yyyy): To (mm/yyyy): Street Address City/Town/Village State ZIP Country (if not USA)
- Office address (if applicable): Name of Office and Street Address City/Town/Village State ZIP Country (if not USA) Telephone E-mail (if any) B. Education
- List all colleges, universities and professional schools (other than law schools) attended. Provide a chronological listing (from earliest to latest). If you did not receive a degree, state the reason. Dates of Attendance From (mm/yyyy): To (mm/yyyy): Name of College / University / Other Degree Street Address City/Town/Village State ZIP Country (if not USA) Reason for not receiving a degree (if applicable) Dates of Attendance From (mm/yyyy): To (mm/yyyy): Name of College / University / Other Degree Street Address City/Town/Village State ZIP Country (if not USA) Reason for not receiving a degree (if applicable) Dates of Attendance From (mm/yyyy): To (mm/yyyy): Name of College / University / Other Degree Street Address City/Town/Village State ZIP Country (if not USA) Reason for not receiving a degree (if applicable)
Application for Admission Q uestionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
- Have you ever been requested or advised by any college, law school, or other professional or graduate school for any reason to discontinue your studies therein? No Yes (if “Yes” answer below) Name of Institution Date (mm/yyyy) Reason and Circumstances: C. Employment
- List every employment you have had since you reached the age of 21, or in the last 10 years, whichever period is shorter, in chronological order (from earliest to latest). Include your current employment, if any. Include self- employment, clerkships, temporary or part-time employment, military service, employment by members of family or other relatives, employment with or without monetary compensation, law-related work-study employment, and law- related employment for academic credit only, including participation in law school clinics and externships, and work as a research assistant. Note to applicants applying for admission on examination: do not include employments listed on your 50 hour pro bono compliance affidavit or listed on your pro bono scholars program completion affidavit. Form Affirmations as to Applicant’s Law-Related Employment and/or Solo Practice: For each law- related employment or period of solo law practice listed in reply to this question, please submit an original form affirmation. If you have not had any law-related employment, submit a letter addressed to the Appellate Division on the letterhead of your present employer, or if you are not presently employed, from your last employer, giving (a) the nature of the services you rendered, (b) the period of employment, (c) the reason you left, and (d) a brief evaluation of your character. Note to applicants applying for admission on examination: do not submit an employment affirmation for employments listed on your 50 hour pro bono compliance affidavit or listed on your pro bono scholars program completion affidavit. Period From (mm/yyyy) Period To (mm/yyyy) Name of Employer Position(s) Held Employer’s Address City/Town/Village State ZIP Country (if not USA) Telephone Nature of Employer’s Business Reason for Leaving or Termination:
Application for Admission Q uestionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications Period From (mm/yyyy) Period To (mm/yyyy) Name of Employer Position(s) Held Employer’s Address City/Town/Village State ZIP Country (if not USA) Telephone Nature of Employer’s Business Reason for Leaving or Termination: Period From (mm/yyyy) Period To (mm/yyyy) Name of Employer Position(s) Held Employer’s Address City/Town/Village State ZIP Country (if not USA) Telephone Nature of Employer’s Business Reason for Leaving or Termination: Period From (mm/yyyy) Period To (mm/yyyy) Name of Employer Position(s) Held Employer’s Address City/Town/Village State ZIP Country (if not USA) Telephone Nature of Employer’s Business Reason for Leaving or Termination:
Application for Admission Q uestionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications List any action now pending against such firm or corporation and any judgment entered against it during the period of your association with it.
- In connection with any employment, whether or not listed in question 14 , have you ever been discharged or requested to resign from or leave your position for cause? No Yes If ‘Yes’, give the name of each such employer and state the date and circumstances as to each such incident. D. Bar Admissions and Other Registrations/Licenses
- Have you ever applied for admission to the Bar of the State of New York in this or any other Department ( see CPLR § 9405), including admission pro hac vice ( see 22 NYCRR 520.11) or for registration as in-house counsel, or for license as a foreign legal consultant in this State ( see 22 NYCRR Parts 521 and 522)? No Yes If ‘Yes’, explain (with dates and disposition).
- Have you ever applied to take or taken the Bar examination in any country, state or jurisdiction other than the State of New York? No Yes
Application for Admission Q uestionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
- Have you ever applied for admission to practice as an attorney in any country, state or jurisdiction other than the State of New York? No Yes If your answer to questions 18 or 19 is ‘Yes’, state specifically the result of the Bar examination and/or the disposition made of the application. If admitted, state the name of each jurisdiction and court by which admitted and the date of such admission. Do not include applications to United States federal courts in your response. Applicants Admitted in Other States or Countries Must Submit: (1) an original certificate of good standing at the Bar from each such jurisdiction and (2) an original letter from each such jurisdiction’s grievance committee, or other body entertaining complaints against lawyers, where available, certifying as to whether charges have ever been filed with such committee or body against you, and, if so, the substance of the charges and the disposition thereof. Certificates of good standing and grievance letters should not be dated more than 60 days prior to submission. You do not need to submit certificates or letters from any United States federal court in which you have been admitted to practice.
- Have you ever engaged in or has your conduct ever been called into question with reference to the unauthorized practice of law? No Yes (if “Yes” explain)
- Have you ever been employed by or otherwise connected with any person, firm or corporation who or which, to your knowledge, engaged in conduct that was called into question on the subject of unauthorized practice of law while you were so employed or connected? No Yes (if “Yes” explain)
Application for Admission Q uestionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
- Note: Answer only if you answered ‘Yes’ to questions 23 or 24. As a member of any armed forces, have you been the subject of any charge, or have any proceedings been instituted against you, or have you been a defendant in any court martial proceeding? No Yes (if “Yes” state the facts below) F. Interactions with Law Enforcement The Appellate Division of the Supreme Court and its Committee on Character and Fitness have a statutorily imposed obligation to carefully investigate the character and fitness of every applicant seeking admission to the practice of law in New York (see CPLR 9404; Judiciary Law § 90 [1] [a]). The information requested here is considered in furtherance of that obligation; like all information disclosed in this application, it is treated confidentially (see Judiciary Law § 90 [10]). An applicant may be denied admission where the applicant’s past conduct demonstrates that the applicant does not possess the character and general fitness requisite for an attorney and counselor-at-law. The mere fact that an applicant’s past includes an arrest, conviction, involvement in juvenile delinquency or youthful offender proceedings or other interactions with law enforcement is not, by itself, a basis on which an applicant is denied admission. Nevertheless, the burden of proving that an applicant possesses the requisite character and fitness to practice law is borne by the applicant. Candor throughout the admission process is required of all applicants, and even convictions that have been expunged should be disclosed in response to this question. Please provide a statement setting forth the facts underlying any incident disclosed here; if police and court records are deemed necessary following review of your application, they will be requested at that time.
- Have you ever, either as an adult or a juvenile, been cited, ticketed, arrested, taken into custody, charged with, indicted, convicted or tried for, or pleaded guilty to, the commission of any felony or misdemeanor or the violation of any law, or been the subject of any juvenile delinquency or youthful offender proceeding? Traffic violations that occurred more than ten years before the filing of this application need not be reported, except alcohol or drug- related traffic violations, which must be reported in all cases, irrespective of when they occurred. Do not report parking violations. No Yes (if “Yes” answer below) Name and Locality of Court Charge or Charges Disposition Thereof and Underlying Facts, Including Relevant Dates:
Application for Admission Q uestionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications G. Civil Matters
- State whether you have ever testified, refused to testify, or been granted immunity, as a complainant, party or witness in any action or proceeding, or before any prosecuting or investigative agency in any matter. No Yes
- State whether you have ever failed to answer any ticket, summons or other legal process served upon you at any time. No Yes
- If you answered ‘Yes’ to question 28 , was any warrant, subpoena or further process issued against you as a result of your failure to respond to such legal process? No Yes
- State whether there are any unpaid traffic or parking tickets in your name or attributable to a motor vehicle registered in your name; if ‘Yes’, please complete the following. No Yes Description of unpaid ticket(s) Fines - Amount(s) due and Date(s) due
- State whether you have ever been charged with fraudulent conduct or any other act involving moral turpitude. No Yes
- State whether you have ever been a complainant, party or witness to or otherwise involved in any civil or criminal action, proceeding or investigation not covered by answers to the above questions 27-31. No Yes If you answered ‘Yes’ to any of the above questions 27-32, indicate the question and state the facts as fully as possible. If applicable, provide the name and locality of the court or agency, the approximate date of the action or proceeding, and the judgment or other disposition. H. Conduct Relevant to Fitness to Practice The Appellate Division of the Supreme Court and its Committees on Character and Fitness have a statutorily imposed obligation to carefully investigate the character and fitness of every applicant seeking admission to the practice of law in New York ( see CPLR 9404; Judiciary Law § 90 [1] [a]). The information requested here is considered in furtherance of that obligation; like all information disclosed in this application, it is treated confidentially ( see Judiciary Law § 90[10]). This section requires full and candid disclosure of conduct and behavior that may call into question your ability to practice law in a competent, ethical or professional manner. While an applicant may be denied admission when the applicant’s ability to function is impaired in a manner relevant to the fitness to practice law, past or present treatment for a condition or impairment is viewed favorably by the Appellate Division of the Supreme Court and its Committees on Character and Fitness. Indeed, applicants who may benefit from treatment are encouraged to seek it.
Application for Admission Q uestionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
- Except as otherwise disclosed in this application, within the past seven years, have you exhibited or engaged in any conduct or behavior, including conduct or behavior resulting from a condition or impairment, that could call into question your ability to practice law in a competent, ethical, and professional manner? No Yes Relevant Date(s) Explanation:
- Are you currently using any illegal drugs? No Yes I. Child Support
- As of the date this application is filed, state whether you are or are not under an obligation to pay child support. I Am I Am Not If you answered ‘I Am’, answer the following questions: (a) Are you four months or more in arrears in the payment of child support? No Yes (b) Are you making payments by income execution or by court agreed payment or repayment plan or by plan agreed to by the parties? No Yes (c) Is the child support obligation the subject of a pending court proceeding? No Yes (d) Are you receiving public assistance or supplemental security income? No Yes If you answered ‘Yes’ to question 37 a, but ‘No’ to 37 b, c, or d, please explain. PLEASE NOTE THAT PERSONS WHO ARE FOUR MONTHS OR MORE IN ARREARS IN CHILD SUPPORT OR WHO HAVE FAILED TO COMPLY WITH A SUMMONS, SUBPOENA OR WARRANT RELATING TO A PATERNITY OR CHILD SUPPORT PROCEEDING MAY BE SUBJECT TO SUSPENSION OF THEIR BUSINESS, PROFESSIONAL, DRIVER’S AND/OR RECREATIONAL LICENSES AND PERMITS INCLUDING, BUT NOT LIMITED TO, LICENSES ISSUED PURSUANT TO ENVIRONMENTAL CONSERVATION LAW § 11-0713. Please further note that the intentional submission of false written statements for the purpose of frustrating or defeating the lawful enforcement of support obligations is punishable pursuant to section 175.35 of the Penal Law of the State of New York.
Application for Admission Q uestionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications J. Financial Matters / Defaults
- Are there any unsatisfied judgments against you? No Yes If ‘Yes’, list the same giving the name and address of the judgment creditor and the court by which judgment was made, together with the date and amount thereof and the nature of the claim on which it was based. Judgment Creditor Name Judgment Creditor Address Court Date (mm/dd/yyyy) Amount Nature of Claim:
- Are you in default in the performance or discharge of any duty or obligation imposed upon you by a judgment, decree, order or directive of any court or governmental agency? No Yes If ‘Yes’, state the facts.
Application for Admission Q uestionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
- Have you ever applied for or been granted a discharge in bankruptcy? No Yes If ‘Yes’, briefly state the facts, including the reason for bankruptcy, date of petition, date of discharge or other disposition and court. K. Licenses / Bonds Please answer both questions 42 and 43.
- (a) Have you ever applied for a license the procurement of which required proof of good character (other than Bar applications listed under question 17–19 above)? No Yes If granted, state, as to each such license, the approximate date it was granted and the name of the authority granting it. License(s) Date(s) Granted (mm/yyyy) Name(s) of Authority
Application for Admission Q uestionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications (b) If your application for such a license was not granted, state the facts. (c) If any such license was revoked or suspended, state the facts.
- Has anyone ever sought to recover on or cancel a fidelity bond on account of your conduct in connection with a bonded position held by you? No Yes If ‘Yes’, specify the nature of your position, the dates during which you were bonded, and the underlying circumstances. Position Date Bonded From (mm/yyyy) Date Bonded To (mm/yyyy) Underlying Circumstances:
Application for Admission Q uestionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications This Application for Admission Questionnaire Must Be Signed and Notarized as Indicated Below. STATE (COUNTRY) OF COUNTY OF CITY OF I (name of applicant), , SWEAR (OR AFFIRM) THAT: I have read the foregoing questions and have fully, truthfully and accurately answered the same. The foregoing answers are true of my own knowledge, except if stated to be made upon information and belief, and as to such answers, I believe them to be true. I authorize the Appellate Division of the Supreme Court and its Committees on Character and Fitness to investigate my character and general fitness to practice law and to contact individuals and entities listed in this Application for Admission for the purpose of ascertaining my character and fitness to practice law. I further authorize such individuals and entities to communicate with the Appellate Division of the Supreme Court and its Committees on Character and Fitness in this regard to provide such clarification and/or further information and documentation as they require. I hereby release, discharge, and exonerate the Appellate Division of the Supreme Court and its Committees on Character and Fitness, their members, agents and representatives, as well as any person furnishing information to the committee from any and all liability of every nature and kind in the course of their duties arising out of the investigation made by the Appellate Division into my moral character, professional reputation, and general fitness for the practice of law, including, without limitation, the inspection of documents, records, and other information related to my treatment for any mental health, drug, alcohol or other substance related condition, or any addiction. Signature of Applicant Dated (mm/dd/yyyy) Subscribed and sworn to or affirmed before me this day of in the year 20. Notary Public* (Sign & Affix seal or stamp)
- If application questionnaire is sworn to outside the United States, its commonwealths, territories, or possessions, and the attesting officer is not a notary public, attach a certificate of the attesting officer’s authority to attest to or witness the signature of the affiant in the jurisdiction.
Application for Admission Q uestionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications ADDENDUM: DESIGNATION OF AGENT This designation must be completed only by applicants who do not reside and are not employed full time in the State of New York ( see 22 NYCRR 520.13). I (name of applicant), , do hereby appoint the Clerk of the Appellate Division, Judicial Department,* as my agent upon whom process may be served with like effect as if served upon me personally, in any action or proceeding hereafter brought against me and arising out of or based upon any legal services rendered or offered to be rendered by the undersigned in the State of New York. Signature of Applicant Dated (mm/dd/yyyy) STATE (COUNTRY) OF COUNTY OF CITY OF On the day of in the year 20 before me, the undersigned, personally appeared , personally known to me or proved to me on the basis of satisfactory evidence to be the individual whose name is subscribed to the above designation of agent and acknowledged to me that he or she executed the same, and that by his or her signature on the designation of agent he or she executed the designation of agent. Officer qualified to administer oath (Notary Public)** (Sign & Affix seal or stamp)
- Enter the Appellate Division Department in which you are being licensed. ** If designation of agent is sworn to outside the United States, its commonwealths, territories, or possessions, and the attesting officer is not a notary public, attach a certificate of the attesting officer’s authority to attest to or witness the signature of the affiant in the jurisdiction.
