APPLICATION FORM

UNITED STATES MAGISTRATE JUDGE

Instructions:	Type or legibly print your answers. If a question is not applicable, indicate this by marking "N/A." Return completed form by October 25, 2013 to:

J. T. Noblin, Clerk

U. S. District Court

501 E. Court St., Suite 2.500

Jackson, MS 39201

GENERAL

1.	Full name:

2.	All other names by which you have been known:

3.	Office address (including city, state and zip code):

Telephone:

4.	Residential address (including city, state and zip code):

Telephone:

5.	Place of birth:

6.	Length of residence in state:

7.	If you are a naturalized citizen, state the date and place of naturalization.

8.	Military service:

Branch:

Dates of service:

Rank or Rate at Discharge:

Type of Discharge:

If still a reserve or national guard member, give service, branch, unit, and present rank:

9.	Are you related by blood or marriage to any judges of this court?

Yes ______ No ______

If yes, give name(s) and relationship(s).

HEALTH

10.	What is the present state of your health?

11.	Do you have any mental or physical impairment that would affect your ability to perform the duties of a magistrate judge without reasonable accommodation?

EDUCATION

12.	Colleges and universities attended, dates, and degrees:

13.	Continuing legal education courses completed within the last 10 years:

HONORS

14.	Were you a member of a law review?	Yes ______ No _______

If yes, describe role:

15.	If you have published any legal books or articles, list them, giving citations and dates.

16.	List any honors, prizes, and/or awards you have received.

PROFESSIONAL ADMISSIONS

17.	List all courts (including state bar admissions) and administrative bodies having special admission requirements in which you are presently admitted to practice, giving the dates of admission in each case:

LAW PRACTICE

18.	State the names, addresses and dates of employment for all law firms, government agencies, and all private business organizations in which you have been employed since your graduation from law school. Also provide all dates during which you have practiced as a sole practitioner.

Organization	Address	Position	Dates

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

19.	Describe the general nature of your current practice including any legal specialties and character of your typical clients; also, if your practice is substantially different now than previously, give details of prior practice.

20.	(a)	Do you appear regularly in court?	Yes ______ No ________

(b)	What percentage of your appearances in the last five years were in:

(1)	Federal courts	______%

(2)	State or local courts of record	______%

(3)	Administrative bodies	______%

(4)	Other:

_____________________	____%

_____________________	____%

_____________________	____%

21.	During the past five years, what percentage of your practice has been trial practice?

______%

22.	How frequently have you appeared in court?

______ times per month

23.	How frequently have you appeared at administrative hearings?

______ times per month

24.	What percentage of your practice involving litigation has been:

Civil	______%

Criminal	______%

Other:

___________________	_____%

___________________	_____%

___________________	_____%

___________________	_____%

25.	State the number of cases you have tried to conclusion in courts of record during the past five years, indicating whether you were sole, associate, or chief counsel. Give citations of any reported cases.

26.	Summarize your courtroom experience for the past five years.

27.	State the names and addresses of adversary counsel against whom you have litigated your primary cases over the past five years.

PUBLIC OFFICE

28.	Have you ever run for, or held, public office?	Yes _______ No ________

If yes, give details.

PRIOR JUDICIAL EXPERIENCE

29.	(a)	Have you ever held judicial office or been a candidate for judicial office? If so, state the courts involved and the dates of service, or dates of candidacy.

(b)	If you have held judicial office, state the names and addresses of counsel who have appeared before you who would be knowledgeable of your work, temperament, and abilities.

(c)	Prior quasi-judicial service:

(For each, state the name of agency, position held, type of issues addressed, number of cases adjudicated and dates of service)

BUSINESS INVOLVEMENT

30.	(a)	If you are now an officer, director, or otherwise engaged in the management of any business enterprise, state the name of such enterprise, the nature of the business, the nature of your duties, and whether you intend to resign such position immediately upon your appointment to judicial office.

(b)	Since being admitted to the Bar, have you ever engaged in any occupation, business, or profession other than the practice of law?

Yes ______ No ______

If yes, give the details, including dates.

(c)	During the past five years have you received any fees or compensation of any kind, other than for legal services rendered, from any business enterprise, institution, organization, or association of any kind?

Yes ______ No _______

If yes, identify the source of such compensation, the nature of the business enterprise, institution, organization or association involved, and the dates such compensation was paid.

31.	(a)	Have you ever been arrested, charged, or convicted for violation of any federal law, state law, county or municipal law, regulation, or ordinance?

Yes ______ No ______

If yes, give details. (Do not include traffic violations for which a fine of $200 or less was imposed unless it also included a jail sentence.)

(b)	Have you, to your knowledge, ever been under federal, state or local investigation for possible violation of a criminal statute?

Yes ______ No_______

If yes, give particulars.

32.	(a)	Have you ever been sued by a client?	Yes ______ No _______

If yes, give particulars.

(b)	Have you or your professional liability insurance carrier ever settled a claim against you for professional malpractice?	Yes ______ No _______

If yes, give particulars, including the amounts involved.

33.	Have you ever been charged in any civil or criminal proceedings with conduct alleged to involve moral turpitude, dishonesty, or unethical conduct?

Yes ______ No ______

If yes, give particulars.

34.	Have you ever been disciplined or cited for a breach of ethics or unprofessional conduct by any court, administrative agency, bar association, or other professional group?

Yes ______ No ________

If yes, give particulars.

35.	Have you filed appropriate tax returns as required by federal, state, local, and other government authorities?	Yes ______ No ______

If no, explain.

36.	Have any liens or claims ever been instituted against you by the federal, state or local authorities?	Yes ______ No ______

If yes, explain.

PROFESSIONAL AND OTHER ACTIVITIES

37.	(a)	List all bar associations and legal professional societies of which you are a member and give the titles and dates of any office you have held in such groups, and committees to which you belonged.

(b)	List all organizations and clubs, other than bar associations and professional societies identified in response to Question No. 36(a), of which you have been a member during the past ten years, including the titles and dates of any offices you have held in each such organization.

SUPPLEMENTAL INFORMATION

38.	State any achievements or actions you have accomplished, demonstrating your commitment to equal justice under the law.

39.	State any additional education or other experiences you believe would assist you in holding judicial office.

40.	State any other pertinent information reflecting positively or adversely on you which you believe should be disclosed to the district court and the selection panel in connection with your possible selection as United States magistrate judge.

41.	(a)	List names, addresses and telephone numbers of three individuals as references who are familiar with your abilities.

(b)	List names, addresses and telephone numbers of three individuals as references who are familiar with your personal character.

CONFIDENTIALITY STATEMENT

This form will be kept confidential and will be examined only by members of the merit selection panel and the judges of the district court. The individuals whom you have listed as references above may be contacted by the panel, but no other employers, colleagues, or other individuals will be contacted without your prior approval.

I declare under penalty of perjury that the foregoing is true and correct.

Date____________	Signature of Applicant_________________________________________