UNITED STATES DISTRICT COURT
CENTRAL DISTRICT OF CALIFORNIA
Pro Bono Panel Application Form
I am applying to become a member of the Central District of California Pro Bono Panel.
The following information is supplied in support of this application:
Name:
LAST FIRST MIDDLE
Business:
FIRM NAME BUSINESS TELEPHONE EXTENSION
STREET ADDRESS SUITE BUSINESS FAX
CITY STATE ZIP CODE BUSINESS E-MAIL ADDRESS
State Bar Memberships:
STATE BAR ID NUMBER DATE OF ADMISSION
STATE BAR ID NUMBER DATE OF ADMISSION
STATE BAR ID NUMBER DATE OF ADMISSION
Date Admitted to the Bar of this Court: . Total number of years of legal practice: .
Of total caseload, percentage of cases personally handled in federal court within the last five (5) years: %
PRO BONO APPLICATION FORM Page 1 of 2
Please provide the names, addresses and telephone numbers of two (2) references (whom the Court may
contact) who are members of the Bar of the United States District Court for the Central District of California:
(1)
NAME
BUSINESS ADDRESS BUSINESS TELEPHONE EXTENSION
CITY STATE ZIP CODE OTHER NUMBER (HOME, MOBILE, ETC.)
(2)
NAME
BUSINESS ADDRESS BUSINESS TELEPHONE EXTENSION
CITY STATE ZIP CODE OTHER NUMBER (HOME, MOBILE, ETC.)
I understand that as a member of the Panel, I agree to accept an appointment as counsel for a pro se litigant in a
civil rights case at least once a year.
DATED SIGNATURE OF APPLICANT
Please email the completed application to
[email protected].
PRO BONO APPLICATION FORM Page 2 of 2
