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NDCLCI Po Box 149 Valley City ND 58072 Phone 701 845-8632 Fax 701 845-8633 Email clcivc nd. gov APPLICATION FOR CONFLICT COUNSEL APPOINTMENT ND COMMISSION ON LEGAL COUNSEL FOR INDIGENTS SFN 59702 2/2014 I hereby apply to handle conflict Criminal Juvenile indigent defense cases in ND. Attorney Name Firm Office/Firm Address City State Telephone Number office Fax Number Email Address office ZIP Code Legal Training Bar Admissions List jurisdictions and ID Number for each jurisdiction Have you ever been the subject of any professional disciplinary complaint which resulted in a reprimand or in any restrictions on a license to practice law Yes No If yes please explain List any other advanced degrees special qualifications potentially applicable to specific types of criminal cases and foreign languages in which you may be fluent Attorneys must maintain compliance with continuing legal education requirements of their licensing state. Additionally to remain on as a conflict attorney you need the following within a two 2 year period Complete ten 10 hours of continuing legal education specific to criminal defense. Do you agree to comply with the continuing legal education requirements declaration page must be sent to the ND Commission on Legal Counsel for Indigents. Please list experience as an attorney with indigent criminal or juvenile cases including internships Please describe any unique or unusual types of cases you have handled areas of emphasis or specialization in your practice. For example tax matters mental health issues stand-by counsel wire intercepts DNA or other forensic areas. If you lack experience defending indigent criminal or juvenile cases would you agree to participate without compensation in a case with a more experienced attorney who would act as a mentor If you have not previously served as a contractor for a public defender of the ND Commission on Legal Counsel for Indigents please provide us with up to three 3 references who are familiar with your legal work. Please include name and contact information* May use separate sheet At which court locations do you wish to be considered for conflict appointments Northwest District North Central District Northeast Central District Southeast District East Central District Appellate Do you have any appellate experience Briefly describe I understand that if I am appointed on any matters before the district court that appointment may continue through any appeal that may be taken as well as any related proceeding that may result from the appeal process unless other counsel is appointed per the agency s standards and policies. Attorney Name Firm Office/Firm Address City State Telephone Number office Fax Number Email Address office ZIP Code Legal Training Bar Admissions List jurisdictions and ID Number for each jurisdiction Have you ever been the subject of any professional disciplinary complaint which resulted in a reprimand or in any restrictions on a license to practice law Yes No If yes please explain List any other advanced degrees special qualifications potentially applicable to specific types of criminal cases and foreign languages in which you may be fluent Attorneys must maintain compliance with continuing legal education requirements of their licensing state. Additionally to remain on as a conflict attorney you need the following within a two 2 year period Complete ten 10 hours of continuing legal education specific to criminal defense.

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