Arizona Supreme Court Committees, Commissions, Councils & Boards
Volunteer/Member Information Form
To be completed by all volunteers interested in serving, or continuing to serve on a Supreme Court Committee, Commission, Council or Board.
Admitted to Practice Law in the State of Arizona
Date: State Bar #:
I am Interested in Serving/Continuing to Serve
on the Following Entities:
STATEMENT OF INTEREST
(Describe why you are interested in serving in this professional activity and volunteer on a Supreme Court
Committee, Commission, Council or Board. Attach extra page if more space needed)
______________________________________________________________________________________________________
PROFESSIONAL AND/OR COMMUNITY SERVICE ACTIVITIES
(Include date(s) of service, and title of office(s) held, if
applicable. Attach extra page if more space needed)
______________________________________________________________________________________________________
NEW VOLUNTEER/MEMBERS - Please List Three References
(Personal and/or professional)
To your knowledge, have any formal charges of professional misconduct, criminal misdemeanor, or a felony ever been filed against you?
Yes ( ) No ( )
If yes, please attach explanation.
Is there any possible conflict of interest or other matter that would create problems or prevent you from fairly and impartially discharging
your duties as an appointee of the Supreme Court? Yes ( ) No ( )
If yes, please attach explanation.
I certify that the facts contained in this application are true and correct to the best of my knowledge. I authorize investigation of all statements
contained herein and the references listed above to give you any and all information concerning my qualifications and any pertinent information
they may have, personal or otherwise, and release all parties from all liability for any damages that may result from furnishing the same to
you. Said investigation may include a criminal history investigation pursuant to A.R.S. §41-1750(G)(2).
Signature_/s/______________________________________________ Date_________________________
Committee staff will retain this form for a period of one year from the date of its receipt. It is the responsibility of the volunteer to notify staff
if he/she wishes to be considered for other entities during the one-year timeframe.
