NDCLCI Po Box 149 Valley City, ND 58072 Phone: (701)845-8632 Fax: (701)845-8633 Email:
[email protected]
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?
Yes
No
Attorney must have malpractice insurance at the time they are taking cases, and a copy of the malpractice insurance declaration page must be sent to the ND Commission on Legal Counsel for Indigents. Do you agree to provide the Commission with proof of malpractice insurance?
Yes
No
SFN 59702 (2/2014) Page 2
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? Yes No 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) 1. 2. 3. At which court locations do you wish to be considered for conflict appointments? Northwest District North Central District Northeast District Northeast Central District Southwest District South 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. Yes
No
Attorney Signature
Date
