Fill - Free fillable APPLICATION FOR ADMISSION TO PRACTICE AS AN ATTORNEY PDF form

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 accompa-

nying affidavits and other papers.

A. PERSONAL INFORMATION

1.

State name in full:

FIRST MIDDLE

LAST SUFFIX (JR., III)

2. 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, the period of, and the reason for, the use of each such name; if change of name is by

marriage, so state; if change of name was by court order, so state.

3. Social Security Number: ......................................

4. BOLE ID# (NYS Board of Law Examiners Identification Number): ...

5. State the following: Age:Date of birth (mm/dd/yyyy):

Place of birth:

CITY / TOWN / VILLAGE STATE COUNTRY

6. Are you a citizen of the United States? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes

If NO, state your immigration status:

7. Present residence:

STREET ADDRESS CITY / TOWN / VILLAGE

STATE ZIP COUNTRY (if not USA)

TELEPHONE E-MAIL (if any)

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

1

APPLICATION FOR ADMISSION TO PRACTICE AS AN ATTORNEY

AND

COUNSELOR-AT-LAW IN THE STATE OF NEW YORK

APPLICATION FOR ADMISSION QUESTIONNAIRE

(Please see the General Instructions for guidance on filing complete applications)

APPLICATION FOR (check one): Admission on Examination or Admission on Motion without Examination.

APPELLATE DIVISION (check one):1

ST

DEPT. 2

ND

DEPT. 3

RD

DEPT. 4

TH

DEPT.

Revised: August 2014

Pro Bono Scholars

Program

8. Prior residence:

Provide the last permanent residence where you resided before the address in question 7.

PERIOD FROM (Month / Year): / To (Month / Year): /

STREET ADDRESS CITY / TOWN / VILLAGE

STATE ZIP COUNTRY (if not USA)

9. Office address (if applicable):

NAME OF OFFICE

STREET ADDRESS CITY / TOWN / VILLAGE

STATE ZIP COUNTRY (if not USA)

TELEPHONE E-MAIL (if any)

B. EDUCATION

10. 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 (Month / Year): / To (Month / Year): /

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 (Month / Year): / To (Month / Year): /

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 (Month / Year): / To (Month / Year): /

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 to Practice as an Attorney and Counselor-at-Law in the State of New York

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11. List all law schools attended.

Provide a chronological listing (from earliest to latest). If you did not receive a degree, state the reason.

FORM LAW SCHOOL CERTIFICATES: You must send the Form Law School Certificate to each law school listed

below. Each law school should return the form directly to the Appellate Division.

DATES OF ATTENDANCE from (Month / Year): / To (Month / Year): /

NAME OF LAW SCHOOL DEGREE

STREET ADDRESS CITY / TOWN / VILLAGE

STATE ZIP COUNTRY (if not USA)

REASON FOR NOT RECEIVING A DEGREE (if applicable)

DATES OF ATTENDANCE from (Month / Year): / To (Month / Year): /

NAME OF LAW SCHOOL DEGREE

STREET ADDRESS CITY / TOWN / VILLAGE

STATE ZIP COUNTRY (if not USA)

REASON FOR NOT RECEIVING A DEGREE (if applicable)

NOTE: If you answer Yes to question 12, 13 or 14, give the name of the institution, and state fully the

circumstances and date of each such occurrence.

12. Have you ever been denied admission to any school, college, law school, or other similar institution for

stated cause which might reflect upon your character?

. . . . . . . No

Yes:

if ‘YES’ answer below

NAME OF INSTITUTION DATE

REASON AND CIRCUMSTANCES

13. Have you ever been placed on probation, dropped, suspended, expelled or otherwise been subjected to

discipline by any institution of learning above elementary school level for conduct which might reflect upon

your character?

. . . . . . . . . . . . . . . . . . . . . . No

Yes:

if ‘YES’ answer below

NAME OF INSTITUTION DATE

REASON AND CIRCUMSTANCES

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

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14. 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

REASON AND CIRCUMSTANCES

C. EMPLOYMENT

15. 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.

FORM AFFIDAVITS 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

affidavit. 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 eval-

uation of your character.

PERIOD FROM (Month / Year): / To (Month / Year): /

NAME OF EMPLOYER

EMPLOYER’S ADDRESS CITY / TOWN / VILLAGE

STATE ZIP COUNTRY (if not USA)

TELEPHONE NATURE OF EMPLOYER’S BUSINESS

POSITION(S) HELD

REASON FOR LEAVING OR TERMINATION

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

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PERIOD FROM (Month / Year): / To (Month / Year): /

NAME OF EMPLOYER

EMPLOYER’S ADDRESS CITY / TOWN / VILLAGE

STATE ZIP COUNTRY (if not USA)

TELEPHONE NATURE OF EMPLOYER’S BUSINESS

POSITION(S) HELD

REASON FOR LEAVING OR TERMINATION

PERIOD FROM (Month / Year): / To (Month / Year): /

NAME OF EMPLOYER

EMPLOYER’S ADDRESS CITY / TOWN / VILLAGE

STATE ZIP COUNTRY (if not USA)

TELEPHONE NATURE OF EMPLOYER’S BUSINESS

POSITION(S) HELD

REASON FOR LEAVING OR TERMINATION

PERIOD FROM (Month / Year): / To (Month / Year): /

NAME OF EMPLOYER

EMPLOYER’S ADDRESS CITY / TOWN / VILLAGE

STATE ZIP COUNTRY (if not USA)

TELEPHONE NATURE OF EMPLOYER’S BUSINESS

POSITION(S) HELD

REASON FOR LEAVING OR TERMINATION

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

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PERIOD FROM (Month / Year): / To (Month / Year): /

NAME OF EMPLOYER

EMPLOYER’S ADDRESS CITY / TOWN / VILLAGE

STATE ZIP COUNTRY (if not USA)

TELEPHONE NATURE OF EMPLOYER’S BUSINESS

POSITION(S) HELD

REASON FOR LEAVING OR TERMINATION

PERIOD FROM (Month / Year): / To (Month / Year): /

NAME OF EMPLOYER

EMPLOYER’S ADDRESS CITY / TOWN / VILLAGE

STATE ZIP COUNTRY (if not USA)

TELEPHONE NATURE OF EMPLOYER’S BUSINESS

POSITION(S) HELD

REASON FOR LEAVING OR TERMINATION

16. Are you now, or have you ever been, engaged on your own account or with others in any occupation,

business enterprise, or profession, (other than law and NOT included in question 15) in the State of New

York or elsewhere?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

No Yes

If Yes, give in detail the nature and location thereof and the month and year of the beginning and ending of

your engagement in or connection therewith. If any such business was carried on by you in partnership

with others, give the names and addresses of all partners and the nature of the business. If the business was

carried on by a corporation in which you held any office, state its name, address, nature of the business and

your connection with it.

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

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List any action now pending against such firm or corporation and any judgment entered against it during

the period of your association with it.

17. In connection with any employment, whether or not listed in question 15, 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

18. 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 Rules of Court of Appeals § 520.11)?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes

If Yes, explain:

19. 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

20. 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 19 or 20 is Yes, state specifically the result of the Bar examination and/or the dis-

position made of the application. If admitted, state the name of each jurisdiction and court by which admitted

and the date of such admission.

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

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APPLICANTS ADMITTED IN OTHER STATES OR COUNTRIES MUST ATTACH: (1) an original certificate of admission

and 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, certi-

fying 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.

21. 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:

22. 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:

23. Except for activities comprising part of a law school clinical program or otherwise permitted by law

(see Judiciary Law §§ 478, 484, 495), have you ever tried any action or proceeding, argued any motion,

drawn legal papers other than under the supervision of an attorney, given legal advice or held yourself out

as an attorney in this State? . . . . . . . . . . . . . . . . . . . .

No Yes

If Yes, explain:

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

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E. MILITARY RECORD

Please answer both questions 24 and 25.

24. Have you at any time or in any manner served in any of the armed forces of the United States, including

reserves?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes

If Yes, state:

PERIOD SERVED: From (Month/ Year) / To (Month/ Year) /

WHERE BRANCH OF SERVICE

NATURE OF SERVICE RENDERED

IF DISCHARGED: GIVE DATE AND NATURE OF DISCHARGE

25. Have you served in the armed forces (reserves or otherwise) of any country other than

the United States of America?

. . . . . . . . . . . . . . . . . . . . . . . . . No Yes

If Yes, state:

PERIOD SERVED: From (Month/ Year) / To (Month/ Year) /

NAME OF COUNTRY BRANCH OF SERVICE

REASON FOR SEPARATION FROM SERVICE

26. Note: Answer only if you answered ‘Yes’ to questions 24 or 25:

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:

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

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F. CRIMINAL RECORD

27. 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 re-

ported, 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 state:

NAME AND LOCALITY OF COURT CHARGE OR CHARGES

DISPOSITION THEREOF AND UNDERLYING FACTS

Although a conviction may have been expunged from the records by order of a court, it nevertheless

should be disclosed in the answer to this question. Please note that you should have available and be

prepared to submit or exhibit copies of police and court records regarding any matter you disclose in

reply to this question.

G. CIVIL MATTERS

28. 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

29. State whether you have ever failed to answer any ticket, summons or other legal process

served upon you at any time.

. . . . . . . . . . . . . . . . . . . . . . . . . . No Yes

30. If you answered Yes to question 29, was any warrant, subpoena or further process issued

against you as a result of your failure to respond to such legal process?

. . . . . . . . . No Yes

31. 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

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

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32. State whether you have ever been charged with fraudulent conduct or any other act

involving moral turpitude.

. . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes

33. 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

28-32. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes

If you answered

Yes to any of the above questions 28-33, 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. MENTAL CONDITIONS & IMPAIRMENTS, SUBSTANCE ABUSE AND ADDICTIONS

The purpose of these inquiries is to assist the Appellate Division of the Supreme Court and its Committee on Char-

acter and Fitness in evaluating the applicant’s current fitness to practice law. This information shall be treated con-

fidentially (see Judiciary Law§ 90[10]).

The mere fact of treatment for mental health, alcohol, drug or other substance abuse conditions and impairments or

gambling addiction is not, in itself, a basis on which an applicant is denied admission.

This section is not intended to require disclosure of physical conditions or impairments, general guidance counseling

for smoking disorders, weight loss advice, academic support, matrimonial and family issues, crime victim issues or

career counseling.

An applicant may be denied admission where the applicant's ability to function is impaired in a manner relevant to

the fitness to practice law, or where the applicant demonstrates a lack of candor by his or her responses. This is con-

sistent with the public purpose underlying the licensing responsibilities assigned to the Appellate Division. The

burden of proving an applicant’s fitness to practice law is borne by the applicant.

34. Do you currently have any condition or impairment including, but not limited to a mental, emotional,

psychiatric, nervous or behavioral disorder or condition, or an alcohol, drug or other substance abuse condi-

tion or impairment or gambling addiction, which in any way impairs or limits your ability to practice law?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes

If your answer is Yes, describe the nature of the condition or impairment:

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

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Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

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If your answer is Yes, are the limitations caused by your condition or impairment reduced or

ameliorated because you receive ongoing treatment or because you participate in a monitoring

or support program?

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Yes

If your answer is Yes, the Committee on Character and Fitness may require that you provide an Authoriza-

tion for the Release of Health Information Pursuant to HIPAA (OCA Official Form No.:960) for some or all

of the providers of your treatment. The form is available at www.nycourts.gov/forms/hipaa_fillable.pdf

35. Are you currently using any illegal drugs? . . . . . . . . . . . . . . . . . . . No Yes

36. Within the past five years, have you engaged in any conduct that:

1- resulted in an arrest, discipline, sanction or warning;

2- resulted in termination or suspension from school or employment;

3- resulted in loss or suspension of any license;

4- resulted in any inquiry, any investigation, or any administrative or judicial proceeding by an employer, edu-

cational institution, government agency, professional organization, or licensing authority, or in connection

with an employment disciplinary or termination procedure; or

5- endangered the safety of others, breached fiduciary obligations, or constituted a violation of workplace or

academic conduct rules?

If so, provide a complete explanation and include all defenses or claims that you offered in mitigation or as

an explanation for your conduct.

No Yes

If you answered Yes, furnish the following information:

NAME OF ENTITY BEFORE WHICH THE ISSUE WAS RAISED (I.E., COURT, AGENCY, ETC.)

ADDRESS

CITY / STATE / ZIP TELEPHONE

COUNTRY PROVINCE

NATURE OF THE PROCEEDING

RELEVANT DATE(S)

DISPOSITION, IF ANY

EXPLANATION

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

13

I. CHILD SUPPORT

37. As of the date this application for admission 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 PUR-

SUANT TO ENVIRONMENTAL CONSERVATION LAW § 11-0713.

Please further note that the intentional submission of false written statements for the purpose of frustrating or de-

feating the lawful enforcement of support obligations is punishable pursuant to section 175.35 of the Penal Law of

the State of New York.

J. FINANCIAL MATTERS / DEFAULTS

38. 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 AMOUNT

NATURE OF CLAIM

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

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39. Are you in default in the performance or discharge of any duty or obligation imposed upon you by a judg-

ment, decree, order or directive of any court or governmental agency?

. . . . . . . . . No Yes

If Yes, state the facts.

40. Do you owe any debt for $300 or more, which is past due for over 90 days? . . . . . No Yes

If Yes, list each such debt and state the name and address of the creditor, the amount presently owed, the due

date, and the nature of the debt.

CREDITOR NAME CREDITOR ADDRESS

AMOUNT OWED DUE DATE (MM/DD/YY)

NATURE OF DEBT

CREDITOR NAME CREDITOR ADDRESS

AMOUNT OWED DUE DATE (MM/DD/YY)

NATURE OF DEBT

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

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CREDITOR NAME CREDITOR ADDRESS

AMOUNT OWED DUE DATE (MM/DD/YY)

NATURE OF DEBT

41. 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:

.

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

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K. LICENSES / BONDS

Please answer both questions 42 and 43.

42. a- Have you ever applied for a license the procurement of which required proof of good character (other

than Bar applications listed under questions

18-20 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 DATE GRANTED (MM/YY) NAME OF AUTHORITY

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:

43. 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 DATES BONDED (MM/YY to MM/YY)

UNDERLYING CIRCUMSTANCES

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

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L. LOYALTY / OATHS / RULES OF PROFESSIONAL CONDUCT

44. Have you ever organized or helped to organize or become a member of any organization or group of

persons which, during the period of your membership or association, you knew was advocating or teaching

that the government of the United States or any state or any political subdivision thereof should be over-

thrown or overturned by force, violence or any unlawful means?

. . . . . . . . . . . No Yes

If Yes, state the facts:

45. Please read carefully: I hereby state that I can take and subscribe to an oath or affirmation that I will sup-

port the Constitution of the United States and the State of New York.

I hereby conscientiously affirm that I am, without any mental reservation, loyal to and ready to support

the Constitutions of the United States and the State of New York.

I have read and I will conscientiously endeavor to conform my professional conduct to the Rules of Pro-

fessional Conduct adopted by the Appellate Division (see 22 NYCRR Part 1200).

If you cannot so state, affirm and or endeavor, please explain:

SINCE THIS IS A CONTINUING APPLICATION, I WILL SUBMIT SUCH ADDITIONAL AFFIDAVITS, PAPERS OR

INFORMATION AS MAY BE REQUESTED OR AS MAY BE NECESSITATED BY ANY CHANGE IN MY SITUATION

UP TO THE DATE OF MY APPEARANCE BEFORE THE APPELLATE DIVISION TO BE SWORN IN AS AN AT-

TORNEY AND COUNSELOR-AT-LAW.

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

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STATE (COUNTRY) OF )

COUNTY OF ss.:

CITY OF )

I, , SWEAR (OR AFFIRM) THAT:

NAME OF APPLICANT

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 Committee 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 Committee on Character and Fitness in this regard to provide

such clarification and/or further information and documentation as it requires.

I hereby release, discharge, and exonerate the Appellate Division of the Supreme Court and its Com-

mittee 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 repu-

tation, 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

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.

THIS APPLICATION FOR ADMISSION QUESTIONNAIRE MUST BE SIGNED AND

NOTARIZED AS INDICATED BELOW.

Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York

19

I, , do hereby appoint the Clerk of the Appel-

late 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 un-

dersigned in the State of New York.

Signature of applicant

Dated

STATE (COUNTRY) OF )

COUNTY OF ss.:

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 des-

ignation of agent he or she executed the designation of agent.

Officer qualified to administer oath

(Notary Public)**

(Sign & Affix seal or stamp.)

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).

* Enter the Appellate Division Department in which you are being admitted.

** 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.

Fill Online, Printable, Fillable, Blank APPLICATION FOR ADMISSION TO PRACTICE AS AN ATTORNEY Form

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Fillable APPLICATION FOR ADMISSION TO PRACTICE AS AN ATTORNEY

Fill Online, Printable, Fillable, Blank APPLICATION FOR ADMISSION TO PRACTICE AS AN ATTORNEY Form

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