Character & Fitness

Applicant Information
Applicant Information
Applicant Information
Full Name John Smith
NCBE Number N10000000
Social Security Number ***-**-****
Birth Date January 10, 1961
Place of Birth Carlisle
Email Address sample@email.com
Alternate Email Address
Sex
City of Birth
State/Province of Birth
Country of Birth
Have you ever used or been known by a different name?
Note: Your name(s) will be used as identification in correspondence sent to schools, employers, courts, references, etc. You must provide the full legal name including middle name(s) if applicable.
If Yes (the following information is required for every name):
Include information for all other names (e.g., legal names, nicknames, or aliases) using separate entries.
First
Middle
Last
Used from
to
Reason for use or change
 
Contact Information
Contact Information
Please provide the mailing address and telephone number(s) where you can be reached during the next six months.
Mailing Address
Firm Name Sonic Inc.
Country United States of America
Address 1 3855 Lake Clearwater Place
Address 2 Apt. 222
Address 3
City Sarasota
State/Province Florida
Postal Code 90210
Primary Phone (812) 111-5100
Office Telephone Number (812) 111-5102
Applications, Authorizations and Conduct
Law Student Registration
Have you ever submitted an application to register as a law student?
Note: This question refers to jurisdiction sponsored law student registration programs (not law school applications).
Name and address of bar or licensing authority
Name
Are you admitted?
Please indicate the judicial department to which admitted, and complete FORM 10.
Name of U.S. jurisdiction, tribal court, or foreign jurisdiction
Date application submitted
Country
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Explanation
 
Bar Exam
Have you ever applied to take a bar exam, including the Uniform Bar Exam (UBE)?
Note: Report all exams for which you have applied or registered, even if you did not sit for the exam. Report all exams even if you did not apply for admission to that jurisdiction and regardless of admission status. Omit the MPRE and First-Year Law Student Examinations.
Name and address of bar or licensing authority
Name
Are you admitted?
Please indicate the judicial department to which admitted, and complete FORM 10.
Name of U.S. jurisdiction, tribal court, or foreign jurisdiction
Date application submitted
Date examination taken
Country
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Were you admitted to this jurisdiction?
Admission or readmission date
Bar Number
Admitted/licensed/registered as
Explanation
 
Reason not admitted/licensed/registered
Explanation
 
UBE Score Transfer
Have you ever applied for admission by transferred Uniform Bar Examination (UBE) score?
Name of U.S. jurisdiction
Are you admitted?
Please indicate the judicial department to which admitted, and complete FORM 10.
Date application submitted
Were you admitted to this jurisdiction?
Admission or readmission date
Bar Number
Admitted/licensed/registered as
Explanation
 
Reason not admitted/licensed/registered
Explanation
 
Motion
Have you ever applied for admission on motion?
Name and address of bar or licensing authority
Name
Are you admitted?
Please indicate the judicial department to which admitted, and complete FORM 10.
Name of U.S. jurisdiction, tribal court, or foreign jurisdiction
Country
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Date application submitted
Were you admitted to this jurisdiction?
Admission or readmission date
Bar Number
Admitted/licensed/registered as
Explanation
 
Reason not admitted/licensed/registered
Explanation
 
Diploma Privilege
Have you ever applied for admission by diploma privilege?
Name and address of bar or licensing authority
Name
Are you admitted?
Please indicate the judicial department to which admitted, and complete FORM 10.
Name of U.S. jurisdiction, tribal court, or foreign jurisdiction
Country
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Date application submitted
Were you admitted to this jurisdiction?
Admission or readmission date
Bar Number
Admitted/licensed/registered as
Explanation
 
Reason not admitted/licensed/registered
Explanation
 
Foreign Legal Consultant
Have you ever registered as a foreign legal consultant?
Name and address of bar or licensing authority
Name
Are you admitted?
Please indicate the judicial department to which admitted, and complete FORM 10.
Name of U.S. jurisdiction, tribal court, or foreign jurisdiction
Country
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Date application submitted
Were you admitted to this jurisdiction?
Admission or readmission date
Bar Number
Admitted/licensed/registered as
Explanation
 
Reason not admitted/licensed/registered
Explanation
 
In-House Counsel
Have you ever previously applied for admission, registration, or licensing as in-house counsel in any jurisdiction?
Name and address of bar or licensing authority
Name
Are you admitted?
Please indicate the judicial department to which admitted, and complete FORM 10.
Name of U.S. jurisdiction, tribal court, or foreign jurisdiction
Country
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Date application submitted
Were you admitted to this jurisdiction?
Admission or readmission date
Bar Number
Admitted/licensed/registered as
Explanation
 
Reason not admitted/licensed/registered
Explanation
 
Other Applications
Have you ever otherwise submitted an application to, or been authorized to practice law in, any U.S. or foreign jurisdiction or tribal court?
Name and address of bar or licensing authority
Name
Are you admitted?
Please indicate the judicial department to which admitted, and complete FORM 10.
Name of U.S. jurisdiction, tribal court, or foreign jurisdiction
Country
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Date application submitted
Date examination taken
Were you admitted to this jurisdiction?
Admission or readmission date
Bar Number
Admitted/licensed/registered as
Explanation
 
Reason not admitted/licensed/registered
Explanation
 
Bar Association Membership
Have you ever been or are you currently a member of any mandatory bar association?
If yes, list the full name and address of each mandatory bar association of which you have been or are currently a member.
From
To
Name and address of the bar association
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
Country
Attorney Discipline
Have you ever been disbarred, suspended, censured, or otherwise reprimanded or disqualified as an attorney?
Name and address of the Regulatory Agency
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Case Number, if applicable
Action Taken
Date
Explanation
 
Attorney Complaint
Have you ever been the subject of any charges, complaints or grievances (formal or informal) concerning your conduct as an attorney, including any now pending?
Name and address of the Regulatory Agency
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Case Number, if applicable
Action Taken
Date
Explanation
 
Unauthorized Practice of Law
Have you ever been the subject of any charges, complaints, or grievances (formal or informal) alleging that you engaged in the unauthorized practice of law, including any now pending?
If yes, include a copy of relevant documentation from the regulatory or law enforcement agency.
Name and address of the Regulatory Agency
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Case Number, if applicable
Action Taken
Date
Explanation
 
Sanction or Disqualification
Have sanctions ever been entered against you, or have you ever been disqualified from participating in any case?
If yes, include a copy of the order of sanction or disqualification
Name and address of the Court
Name
Country
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Case Number
Case Name
Action Taken
From
To
Explanation
 
Education
Law Office Study
Did you engage in law office study in lieu of receiving a J.D.?
Date Started
Date Finished or Expect To Be Finished
Name and address of firm
Name
Name of Tutor/Proctor
Country
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Law School Attendance
List complete information regarding all law school attendance and law degrees (J.D., L.L.B., L.L.M., etc.).
Note: If you studied abroad during law school, complete an entry for each study abroad period. Indicate the sponsoring institution, if different from the school listed.
I have attended law school.
Enrollment Status
Did you/will you receive this degree from an ABA approved Law School?
Name of Law School
Provide the name and mailing address of the non-ABA law school/institution you attended
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Attended From
Attended To
Date degree received or expected
Degree received or expected to be received or No Degree
Was your enrollment at this institution primarily through an online degree program?
Law School Discipline
Have you ever been dropped, suspended, warned, placed on scholastic or disciplinary probation, expelled, requested to resign, allowed to resign in lieu of discipline, otherwise subjected to discipline, or requested to discontinue your studies by any law school?
Name of Institution
Action taken
Date action taken
Explanation
 
College/University Attendance
List complete information regarding all college/university attendance (other than law school).
Note: If you studied abroad, complete an entry for each study abroad period. Indicate the sponsoring institution, if different from the school listed.
I have attended College or University
Name and mailing address of college/university
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Attended From
Attended To
Degree received (No degree, B.A., M.S., etc.)
Field(s) of Study
Was your enrollment at this institution primarily through an online degree or program?
College/University Discipline
Have you ever been dropped, suspended, warned, placed on scholastic or disciplinary probation, expelled, requested to resign, allowed to resign in lieu of discipline, otherwise subjected to discipline, or requested to discontinue your studies by any college or university?
Name of Institution
Action taken
Date action taken
Explanation
 
Residences
Residential History
List every permanent or temporary physical address where you have resided for a period of one month or longer for the last ten years or since the age of 18, whichever period of time is shorter.
Date From
Date To
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Employment
Employment History
List your employment and unemployment information for the last ten years or since age 18, whichever period is shorter.
Please list employment history in reverse chronological order. Your most recent employment should be listed first.
NOTES:
Employment - In this context, employment encompasses all part-time and full-time employment, including self-employment, externships, internships (paid and unpaid), clerkships, military service, volunteer work, and temporary employment.
Unemployment - Provide a brief, but specific, description of your activities while unemployed (seeking employment, preparing for law school, attending school name, vacation, studying for bar exam).
Employment References - If an employer is no longer in operation, or you were self-employed or employed by a relative, provide the name and contact information of a verifying reference. Do not list yourself or a relative as a verifying reference.
Details - Places of employment should correspond with places of residence. Indicate if the address provided is a company headquarters or if you worked remotely. Provide other information that may assist in the verification of this period of employment. For any law-related positions (e.g., Law Clerk, Associate, Counsel, Contract Attorney), describe your job responsibilities and identify the specific geographic locations of the offices and jurisdictions from which you conducted your activities.
Are you currently or have you been unemployed?
If Yes (the following information is required for every period of unemployment during the relevant time period):
Unemployed From
Unemployed To
Provide a brief, but specific, description of your activities while unemployed.
 
Are you currently or have you been employed?
From
To
Employment position
Is this a law-related position?
Details
Employer or firm name
Name of supervisor or associate
Address 1
Address 2
Address 3
City
State/Province
Postal Code
Country
Telephone
Email of supervisor or associate
Please choose one of the options
Verifying reference name / Business name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
Country
Email Address
Details
 
Verifying reference name / Business name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
Country
Email Address
Details
 
Verifying reference name / Business name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
Country
Email Address
Details
 
Employment Actions
Have you ever been disciplined, suspended, laid off, permitted to resign (in lieu of termination), or terminated from any job?
Note: If Yes, any associated periods of employment must be listed in response to the Employment History question before proceeding.
Employer
Date of employment from
Date of employment to
Disposition
Date of disposition
Explanation of circumstances
 
Judicial Office
Have you ever held judicial office?
Office Held
From
To
Name and Address of the court
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
If no longer employed, please provide reason for leaving/termination.
Reason for leaving/termination
 
Military Service
Have you ever been a member of the armed forces of the United States, its reserve components, or the National Guard?
Branch of Service
State
Serial number
Rank
From Mo/Yr
To Mo/Yr
Type of Discharge or Separation
 
Are you presently serving personnel?
Current Status
Present duty station
Address 1
Address 2
Address 3
City
State
ZIP Code
Province
Country
Telephone number
Email Address
Name of the commanding officer
Were you ever court-martialed?
Date of action
Explanation of circumstances
 
Result, including any punishment
 
Were you ever awarded non-judicial punishment? (Art. 15 UCMJ)
Date of action
Explanation of circumstances
 
Result, including any punishment
 
Did you receive an honorable discharge?
Date of action
Explanation of circumstances
 
Result, including any punishment
 
Were you allowed to resign in lieu of court-martial?
Date of action
Explanation of circumstances
 
Result, including any punishment
 
Were you administratively discharged?
Date of action
Explanation of circumstances
 
Result, including any punishment
 
Licenses
Have you ever applied for a license (even if the application was subsequently withdrawn) or held a license for a business, trade, or profession, other than as an attorney-at-law?
License Type
Issued to (include business name, if applicable)
Current Status
License number
Application Date
Expiration/Inactive Date
Name and address of issuing authority
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Have you ever been denied a license or had a license revoked for a business, trade, or profession?
Type of License
Issued to (include business name, if applicable)
Current Status of License
License Number
Application Date
Expiration / Inactive Date
Issuing Authority
Address 1
Address 2
Address 3
City
State
Zip Code
Province
Country
Telephone
Please provide the following information for each denial or revocation.
Denial or Revocation
Name of Regulatory Agency
Address 1
Address 2
Address 3
City
State
Zip Code
Province
Country
Action Taken
Date of Action
Explanation
 
Character & Fitness
Professional Discipline
Have you ever been suspended, censured, or otherwise reprimanded or disqualified as a member of another profession, or as a holder of public office?
Name and address of Regulatory or Public Agency
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Case Number
Action Taken
Date
Explanation
 
Professional Complaint
Have you ever been the subject of any charges, complaints, or grievances (formal or informal) concerning your conduct as a member of any other profession, or as a holder of public office, including any now pending?
Name and address of Regulatory or Public Agency
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Case Number
Action Taken
Date
Explanation
 
Bond
Has any surety on any bond on which you were the principal been required to pay any money on your behalf?
Name and address of surety
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Amount of money paid by surety
Date money paid by surety
Reason for bond
 
Detailed explanation
 
Conduct or Behavior
Within the past five years, have you exhibited any conduct or behavior that could call into question your ability to practice law in a competent, ethical, and professional manner?
Explanation
 
Relevant Dates
From Mo/Yr
To Mo/Yr
Condition or Impairment
The mere fact of treatment, monitoring or participating in a support group does not need to be reported, nor is it a basis upon which admission is denied.
Do you currently have any condition or impairment (including, but not limited to, substance abuse, alcohol abuse, or a mental, emotional, or nervous disorder or condition) that in any way affects your ability to practice law in a competent, ethical, and professional manner?
Note: In this context, "currently" means recently enough that the condition or impairment could reasonably affect your ability to function as a lawyer.
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?
Service provided From
Service provided To
Describe any treatment, or any program that includes monitoring or support
 
Name of attending Physician or Counselor
Address 1
Address 2
Address 3
City
State/Province
Postal code
Country
Telephone
Name of Hospital or Institution
Address 1
Address 2
Address 3
City
State/Province
Postal code
Country
Telephone
Describe the condition or impairment
 
Defense or Explanation
The purpose of this inquiry is to allow jurisdictions to determine the current fitness of an applicant to practice law. The mere fact of treatment, monitoring, or participation in a support group is not, in itself, a basis on which admission is denied; jurisdictions' bar admission agencies routinely certify for admission individuals who demonstrate personal responsibility and maturity in dealing with fitness issues. The National Conference of Bar Examiners encourages applicants who may benefit from assistance to seek it.
Within the past five years, have you asserted any condition or impairment as a defense, in mitigation, or as an explanation for your conduct in the course of any inquiry, any investigation, or any administrative or judicial proceeding by an educational institution, government agency, professional organization, or licensing authority; or in connection with an employment disciplinary or termination procedure?
Name of entity before which the issue was raised
Address 1
Address 2
Address 3
City
State/Province
Postal code
Country
Telephone
Nature of the proceeding
Date
Disposition, if any
Explanation
 
Legal Proceedings
Civil Action
Have you ever been a named party to any civil action?
NOTE: Note: Family law matters (including divorce actions and continuing order for child support) should be included here.
If Yes, include a copy of the associated pleadings, judgments, final orders and/or docket report.
Complete title of action
Court file number
Date filed
Name and Address of Court
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Are you the subject of any continuing court order (e.g., for child support or payment of a money judgment)?
Name and address of plaintiff
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Name of plaintiff's attorney
Name and address of defendant
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Name of defendant's attorney
Was this matter taken to trial?
Trial date
Date of final disposition
Disposition
If the disposition resulted in a judgment, has the judgment been satisfied?
Date judgement satisfied
Detailed explanation of civil action
 
Amount still owed
Detailed explanation of civil action
 
Detailed explanation of civil action
 
Administrative Action
Have you ever had a complaint or action (including, but not limited to, allegations of fraud, deceit, misrepresentation, forgery, or malpractice) initiated against you in any administrative forum?
If Yes, include a copy of the associated administrative record.
Date action/complaint initiated
Name and address of Administrative Forum or Body
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Name of investigative agency
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Date of final disposition, if any
Disposition, if any
Explanation
 
Criminal Action
Have you ever been cited for, arrested for, charged with, or convicted of any violation of any law?
Note: Include matters that have been dismissed, expunged, subject to a diversion or deferred prosecution program, or otherwise set aside
If Yes, include a copy of the associated arrest report, complaint, indictment, citation, information, disposition, sentence, docket report, and appeal, if any.
Date (or time period) of incident
Charge(s) on date of arrest or citation
Incident location
City
County
State/Province
Postal Code
Country
Title of complaint, indictment, or citation
Court file number
Name and address of court involved
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Name and address of law enforcement agency involved
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Attorney name
Date of initial court hearing
Charge(s) at time of initial court hearing
Date of final disposition
Charge(s) at time of final disposition
Final disposition
Detailed description of allegation or violation
 
Alcohol or Drug Related Traffic Violation
Have you ever been cited for, arrested for, charged with, or convicted of any alcohol or drug related traffic violation?
Note: Include matters that have been dismissed, expunged, subject to a diversion or deferred prosecution program, or otherwise set aside
If Yes, include a copy of the associated arrest report, complaint, indictment, citation, information, disposition, sentence, docket report, and appeal, if any
Date (or time period) of incident
Charge(s) on date of arrest or citation
Incident location
City
State/Province
Postal Code
County
Country
Title of complaint, indictment, or citation
Court file number
Name and address of court involved
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Name and address of law enforcement agency involved
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Attorney name
Date of initial court hearing
Charge(s) at time of initial court hearing
Date of final disposition
Charge(s) at time of final disposition
Final disposition
Detailed description of allegation or violation
 
Traffic Violation
Have you been cited for, arrested for, charged with, or convicted of any moving traffic violation during the past ten years?
Note: Include matters that have been dismissed, expunged, subject to a diversion or deferred prosecution program, or otherwise set aside. Omit parking violations
Name of law enforcement agency
Violation location
City
County
State/Province
Country
Date of violation
Charge(s) at time of final disposition
Final disposition
Description of violation
Driver's License
Have you held a driver's license during the last ten years?
Driver's License
State/Province
Country
Driver's License number (if unavailable, enter "unknown")
Is this your current driver's license
Financial Responsibility
Revocation
Have you ever had a credit card or charge account revoked that was not resolved in bankruptcy?
Type of Debt
Last four digits of account number
Original amount of debt
Current balance
Have you made a payment?
Date of last payment
Entity extending credit
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Phone Number
Is your current creditor or collection agency different from entity extending credit?
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Phone Number
Current status of this debt
Describe the history of this debt
 
Defaulted Student Loan
Have you ever defaulted on a student loan?
Full account number
Original amount of debt
Current balance
Have you made a payment?
Date of last payment
Entity extending credit
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Phone Number
Is your current creditor or collection agency different from entity extending credit?
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Phone Number
Current account number
Current status of this debt
Describe the history of this debt
 
Other Defaulted Debt
Have you ever defaulted on any debt other than a student loan that was not resolved in bankruptcy?
Type of Debt
Explanation
 
Last four digits of account number
Original amount of debt
Current balance
Have you made a payment?
Date of last payment
Entity extending credit
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Phone Number
Is the name of current creditor or collection agency different from above?
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Phone Number
Current account number
Current status of this debt
Describe the history of this debt
(if this is a medical debt, include date of service and institution name)
 
For real estate debt, provide address of property associated with debt
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Phone Number
Current account number
Past Due Debt
Have you had a debt of $500 or more that has been more than 90 days past due within the past three years that was not resolved in bankruptcy?
Type of Debt
Explanation
 
Last four digits of account number
Original amount of debt
Current balance
Have you made a payment?
Date of last payment
Entity extending credit
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Phone Number
Is your current creditor or collection agency different from entity extending credit?
For real estate and utility/telephone debt, provide address of property/telephone number associated with debt:
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Phone Number
Current account number
Current status of this debt
Describe the history of this debt
 
Tax Debt
Have you ever failed to timely pay any personal taxes due, including but not limited to any federal or state income taxes; state, county or municipal private property taxes; or real estate assessment taxes?
Type of Debt
Explanation
 
Full account number
Original amount of debt
Current balance
Have you made a payment?
Date of last payment
Agency
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Phone Number
Current status of this debt
Describe the history of this debt
(include applicable tax year(s))
Bankruptcy
Have you ever filed a petition for bankruptcy?
Include associated schedule of indebtedness, petition for bankruptcy, docket report and discharge from bankruptcy order
Date filed
Title of action
Type of Bankruptcy
Court File Number/Case Number
Name and address of court involved
Name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
County
Country
Date of disposition
Disposition
Total amount discharged in U.S. dollars
Were any adversary proceedings instituted?
Were there any allegations of fraud?
Were any debts not discharged?
Detailed description of circumstances surrounding filing
 
Character References
References
Provide complete information for at least six references, preferably persons who have known you for a minimum of five years. You are encouraged to include one reference from every locality where you have lived during the last ten years.
Do not list yourself, anyone who is related to you by blood or marriage, or anyone who resides at your current residential address.
Do not use names listed in response to the Employment History question. If you provide a business address, please include the names of both the reference and the business.
Note: To avoid delays, provide current contact information (email address, mailing address, and telephone number) for each reference.
Name
Business name
Address 1
Address 2
Address 3
City
State/Province
Postal Code
Country
Telephone
E-Mail
Occupation
Years Known
Additional Information
Additional Information
Would you like to provide additional information or further explain any of your previous responses?
Explanation