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Palmer .     &)      ;X&yXX;XX&yXX;X&y  _yWGCz hx p @X@Exxxxx (#(#    (#(#(2&$ 9 !      ;X&yXX;XX&yXX;X&y  ݃ Level 1 Level 2 Level 3 Level 4 Level 5(2&$ 9 !      ;X&yXX;XX&yXX;X&y  (2&$ 9 !      ;X&yXX;XX&yXX;X&y  ($'dxdC<< c8DocumentManagement::ModifiedBooleanTRUEv A`WP Phoneticmailto:NYED-APPLICATIONS@nyed.uscourts.gov   &)      ;X&yXX;XX&yXX;X&y  X?+ ` hp x '#X? XWGCz hx p @X@Exxxxx (#(#   (#(# - &"      ;X&yXX;XX&yXX;X&y  ?+ ` hp x '#X?  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X General : x  1.  FullName: D  2.  Allothernamesbywhichyouhavebeenknown: ` 3.  OfficeAddress: ,  XCity `     h   State   p   ZipCode   X  hE.` hp x (#X'#ETelephoneNumber:   p     EMailAddress: Z   hE.` hp x '#XE4.  AllCurrentResidentialAddresses: &v  XTelephoneNumber(s): (  X5.  Timeatcurrentresidence(s): h     Timeofresidenceinstate:  6.  PlaceofBirth:    h   DateofBirth: p!  7.  Ifyouareanaturalizedcitizen,pleasestatethedateandplaceofnaturalization: <#" 8.  MilitaryDuty: %>!%  XService: &$"& Branch: ' #' Dates: (#( Rankorrateatdischarge: )$) Typeofdischarge:   X XB+ ` hp x '#X'#BIfstillaReserveorNationalGuardmember,pleasegiveservice,branch,unitandpresent | rank. b  XE.` hp x '#X'#E  XB+ ` hp x '#X'#B9.  Areyourelatedbybloodormarriagetoanyjudgesofthiscourtortoanymembersofthe . ~ MeritSelectionPanelwhowillreviewthisapplication?Yes___No___.Ifso,givetheir  d names.  J   XE.` hp x '#X'#E Health :    10.  Whatisthepresentstateofyourhealth? x    XE.` hp x (#X'#E11.  Doyouhaveanyvisualorhearingimpairmentorothermentalorphysicalimpairment D  thatwouldrequireaccommodationbytheCourttopermityoutoperformtheduties *z  assignedtoamagistratejudge?Ifso,specify.(BeassuredthattheCourtdoesnot ` discriminateandwillprovidereasonableaccommodationforanyhandicap.) F   XE.` hp x '#XE  XE.` hp x (#X'#E12.  Haveyouhadanyhospitalconfinement,mentalillness,seriousphysicalillness,ordrug t oralcoholaddictionduringthepastten(10)years?Yes___No___.Ifyes,explainand Z providethename,addressandtelephonenumberofyourattendingphysician(s),andall @ hospitalsandotherinstitutionstowhichyouwereadmittedandthedate(s)ofeach &v hospitalization.  \   XE.` hp x '#XE  XE.` hp x (#X'#E13.  Areyoupresentlyreceivingorcontemplatingreceivingtreatmentforaphysicalor   mentalillnessorcondition,orfordrugoralcoholaddiction?Yes___No___.Ifso, p!  pleasegivedetails. V"!   XE.` hp x '#XE Education: %>!%    XE.` hp x (#X'#E14.  Collegesanduniversities(includingprofessionalschools)attended;addresses,datesand ' #' degree(s): (#(   XE.` hp x '#XE )$)      15.  Continuinglegaleducationcoursescompletedwithinthelastten(10)years:   Honors :  J 16.  Wereyouamemberofanylawreview?     XNames `    Positions     p   Dates    X17.  Ifyouhavepublishedanylegalbooksorarticles,listthem,givingcitationsanddates: , 18.  Listanyotherhonors,prizesorawardsyouhavereceived: B  ProfessionalAdmissions : "$r#  XE.` hp x (#X'#E19. ` Listallcourts(includingstatebaradmissions)andadministrativebodieshaving %>!% specialadmissionrequirementsinwhichyouarepresentlyadmittedtopractice,giving &$"& thedatesofadmissionineachcase: ' #'  XE.` hp x '#XE  (#(  XCourtorAdministrativeBody    DateofAdmission   x I.D.Number   X LawPractice :      XE.` hp x (#X'#E20.  Commencingwithyourlawschooladmission,statethenames,positions,dates, x  addressesandtelephonenumbersofalllawfirmswithwhichinanywayyouhavebeen ^  employedorassociatedinpractice,andofallgovernmentalagenciesorprivatebusiness D  organizationsinwhichyouhaveeverbeenemployedorassociated,periodsduringwhich *z  andaddressesfromwhichyouhavepracticedasasolepractitioner,andanylegal ` practiceoremploymentnototherwisecoveredbyyouranswers. F   XE.` hp x '#XE  p!    XE.` hp x (#X'#E21.  Describethegeneralnatureofyourcurrentpractice,includinganylegalspecialtieswhich  youpossessandthecharacterofyourtypicalclients.Additionally,ifyourpracticeis  substantiallydifferentnowfromwhatitpreviouslyhadbeen,pleasegivecomplete | detailsofpriorpractice. b   XE.` hp x '#XE22.  (a) ` Doyouappearregularlyincourt? `  X(b) ` Whatpercentageofyourappearancesinthelastfive(5)werein   X 1. federalcourts h      p   %  2. stateorlocalcourtsofrecord   p   % t 3. administrativebodies     p   % Z 4. other   h      p   % @    XE.` hp x (#X'#E23.  Duringthelastfive(5)years,whatpercentageofyourpracticehasbeentrialpractice?  \   XE.` hp x '#XE X____% (  X  XE.` hp x (#X'#E24.  Duringthelastfive(5)years,howfrequentlyhaveyouappearedincourt?    XE.` hp x '#XE X_______timespermonth p!   X25.  ListthepercentageofyourpracticeinvolvinglitigationwhichhasbeenB <#"  Civil    h % %X $ Criminal   h % %>!% Other    h % &$"&    ' #'  ! XE.` hp x (#X'#E26.  Statethenumberofcasesyouhavetriedtoconclusionincourtsofrecordduringeachof  thepastfive(5)years,indicatingwhetheryouweresole,associate,orchiefcounsel.  Givecitationsofanyreportedcases. |   XE.` hp x '#XE27.  Summarizeyourcourtroomexperienceforthelastfive(5)years:  ^   #! XE.` hp x (#X'#E28.  WithrespecttothecasesqualifiedatQuestion27,aswellasanyothercasesyouhave  litigatedduringthelastfive(5)years,listeachsuchcase,providingabriefdescription,  thename,currentaddress,andtelephonenumberofyouradversaryandofthejudge | beforewhomyouappeared. b   XE.` hp x '#XE PublicOffice : ` 29.  Haveyoueverrunfor,orheld,publicoffice?Yes___No___.Ifso,givedetails. ,  PriorJudicialExperience : t  P E.` ` ` hp x (#X'#E30.(a) ` Haveyoueverheldjudicialofficeorbeenacandidateforjudicialoffice? @  P E.` hp x '#` ` XEYes___No___.Ifso,pleasestatethecourtsinvolvedandthedatesofservice,or '#  &v   datesofcandidacy.  \   X(b) ` PriorQuasijudicialservice: p!   XNameofagency: "" Positionheld: "$r$ Hearingonwhatissues: {% & Numberofcasesadjudicated: &$"( Datesofservice: -(}#*     )$, _%#BusinessInvolvement :   P E.` ` ` hp x (#X'#E31.(a) ` Ifyouarenowanofficer,directororotherwiseengagedinthemanagementof | anybusinessenterprise,statethenameofsuchenterprise,thenatureofthe b business,thenatureofyourpositionandofyourduties,andwhetheryouintendto H resignsuchpositionimmediatelyuponyourappointmenttojudicialoffice, . ~  P E.` hp x '#` ` XE  E.` ` ` hp x (#X'#E(b) ` SincebeingadmittedtotheBar,haveyoueverengagedinanyoccupation,  J business,orprofessionotherthanthepracticeoflaw?Yes___No___.Ifso,give  0 thedetails,includingdates.      E.` hp x '#` ` XE  E.` ` ` hp x (#X'#E(c) ` Statewhetherduringthepastfive(5)yearsyouhavereceivedanyfeesor F compensationofanykindotherthanforlegalservicesrenderedfromany , businessenterprise,institution,organizationorassociationofanykind.Yes___  No___.Ifso,identifythesourceofthebusinessenterprise,institution,  organizationorassociationinvolved,andthedatessuchcompensationwaspaid.    E.` hp x '#` ` XE P E.` ` ` hp x (#X'#E32.(a) ` Haveyoueverbeenarrested,charged,orconvictedforviolationofanyfederal B law,statelaw,countyormunicipallaw,regulationorordinance?Yes___No___. ( Ifso,givedetails.Donotincludetrafficviolationsforwhichafineof$200or  lesswasimposedunlessitalsoincludedajailsentence.   P E.` hp x '#` ` XE  E.` ` ` hp x (#X'#E(b) ` Haveyou,toyourknowledge,foranyreasoneverbeenunderfederal,stateor "$r# localinvestigation?Yes___No___.Ifso,giveparticulars. %X $   E.` hp x '#` ` XE_  (#(  P'%X E.` ` ` hp x (#X'#E33.(a) ` Haveyoueverbeensuedbyaclientforanyreason,includingprofessional  malpractice?Yes___No___.Ifso,giveparticulars.   P E.` hp x '#` ` XE  E.` ` ` hp x (#X'#E(b) ` Haveyouoryourprofessionalliabilityinsurancecarriereversettledaclaim  J againstyouforprofessionalmalpractice?Yes___No___.Ifso,giveparticulars,  0 includingtheamountsinvolved.      E.` hp x '#` ` XE  E.` ` ` hp x (#X'#E_(c)_ ` Haveyoueverbeeninvolvedasapartytoanylitigation(criminal,civilor D  administrative)?Yes___No___.Ifso,giveparticulars. *z    E.` hp x '#` ` XE P E.` ` ` hp x (#X'#E34.(a) ` Haveyoueverbeendisciplined,cited,admonishedorcautionedforabreachof  ethicsorunprofessionalconductbyanycourt,administrativeagency,bar t association,orotherprofessionalgroupor,withoutregardtotheoutcome,toyour Z knowledge,hasthereeverbeenacomplaintpreferredagainstyouwithorbyany @ court,administrativeagency,barassociationorotherprofessionalgroup?Yes___ &v No___.Ifso,givetheparticulars.  \  P E.` hp x '#` ` XE  E.` ` ` hp x (#X'#E(b) ` Haveyoueverbeenquestionedbyanypersonorprivateorpublicentity p!  concerninganypossiblemisconduct,incompetence,unsatisfactoryperformance V"! ofdutyorviolationoflaw?Yes___No___.Ifyes,giveparticulars. <#"   E.` hp x '#` ` XE  E.` ` ` hp x (#X'#E_(c)_ ` Toyourknowledge,haveyoueverbeenthesubjectofaninvestigationbyany ' #' personorprivateorpublicentityconcerninganypossiblemisconduct, (#( incompetence,unsatisfactoryperformanceofduty,orviolationoflaw?Yes___ )$) No___.Ifyes,giveparticulars. l*%*   E.` hp x '#` ` XE 8,', Ї ) E.` ` ` hp x (#X'#E(d) ` Haveyou,toyourknowledge,everbeenfoundnotqualifiedforanypublic  positionbyanycourt,administrativeagency,barassociationorotherprofessional  group?Yes___No___.Ifyes,giveparticulars. |   E.` hp x '#` ` XE  E.` ` ` hp x (#X'#E(e) ` Haveyoueverbeendisciplinedorterminatedbyorbecauseofpossible  J terminationresignedfromanypublicorprivateemployer,lawfirmoranyother  0 entitybecauseofanymisconduct,incompetenceorunsatisfactoryperformancein    anyrespect?Yes___No___.Ifyes,giveparticulars.      E.` hp x '#` ` XE  E.` ` ` hp x (#X'#E(f) ` Haveyoueverresignedfromor,forotherreasons,ceasedtobeamemberofthe *z  barorbenchofanystateorcourtinanyjurisdiction,amemberofany ` governmentalbody,ahearingofficeroranoccupantofanyothersimilar F position?Yes___No___.Ifso,giveparticulars. ,   E.` hp x '#` ` XE  XE.` hp x (#X'#E35.  HaveyoufiledappropriatetaxreturnsasrequiredbyFederal,State,Local,andother @ Governmentauthoritiesinatimelyfashion?Yes___No___.Ifno,explain. &v   XE.` hp x '#XE P E.` ` ` hp x (#X'#E36.(a) ` Haveanyliensorclaimseverb4eeninstitutedagainstyoubytheFederal,Stateor  localauthorities?Yes___No___.Ifyes,explain.   P E.` hp x '#` ` XE  E.` ` ` hp x (#X'#E(b) ` Doyouhaveanysummonses,trafficticketsorothersuchclaimsoutstanding <#" againstyoubyanyfederal,stateorlocalauthorities?Yes___No___.Ifyes,give "$r# particulars. %X $   E.` hp x '#` ` XE  E.` ` ` hp x (#X'#E_(c)_ ` Arethereanyunsatisfiedjudgmentsagainstyou?Yes___No___.Ifyes,give (#( particulars. )$)   E.` hp x '#` ` XE  8,', )  )*' )  ,*  E.` ` ` hp x (#X'#E(d) ` Areyouindefaultintheperformanceordischargeofanydutyorobligation  imposeduponyoubyanygovernmentalagencyordecreeororderofanycourt,  includingalimony/maintenanceandsupportordersanddecrees?Yes___No___. | Ifyes,giveparticulars. b   E.` hp x '#` ` XE  E.` ` ` hp x (#X'#E(e) ` Haveyouevermadeanassignmentforthebenefitofcreditors?Yes___No___.  J Ifyes,giveparticulars.  0   E.` hp x '#` ` XE  E.` ` ` hp x (#X'#E(f) ` Hasanypetitioninbankruptcyeverbeenfiledbyoragainstyou? x    E.` hp x '#` ` XEYes___No___.Ifyes,giveparticulars. ^    ProfessionalandOtherActivities ,   P E.` ` ` hp x (#X'#E37.(a) ` Listallbarassociationsandlegalprofessionalsocietiesofwhichyouarea  memberandgivethetitlesanddatesofanyofficeyouhaveheldorcurrentlyhold  insuchgroups,andcommitteestowhichyoubelongedorcurrentlybelong: t  P E.` hp x '#` ` XE  E.` ` ` hp x (#X'#E(b) ` Listallorganizationsandclubs,otherthanbarassociationsandprofessional p!  societiesidentifiedinresponsetoQuestion39(a)ofwhichyouhavebeena V"! memberduringthepastten(10)years,includingthetitlesanddatesofanyoffices <#" youhaveheldineachsuchorganization: "$r#   E.` hp x '#` ` XE   8,', ., SupplementalInformation     XE.` hp x (#X'#E38.  Stateanyachievementsoractionsyouhaveaccomplished,demonstratingyour | commitmenttoequaljusticeunderlaw: b   XE.` hp x '#XE  XE.` hp x (#X'#E39.  Stateanyadditionaleducationorotherexperiencesyoubelievewouldassistyouin F holdingjudicialoffice: ,   XE.` hp x '#XE  XE.` hp x (#X'#E40.  Listfive(5)individualsasreferenceswhoarefamiliarwithyourabilitiesandpersonal ( character:    XE.` hp x '#XE XName `     h Address   p     TelephoneNumber    X  )$)  P0.  E.` ` ` hp x (#X'#E41.(a) ` Setforthanyinformationnototherwiseelicitedbythisapplicationwhichwould  affectfavorablyorunfavorably,youreligibilityfortheofficeforwhichyouarea  candidateorbearuponconsiderationofyourcandidacy: |  P E.` hp x '#` ` XE  E.` ` ` hp x (#X'#E(b) ` Stateanypertinentinformationreflectingpositivelyoradverselyonyouwhich ^  youbelieveshouldbedisclosedtothedistrictcourtandtheselectionpanelin D  connectionwithyourpossiblenominationasUnitedStatesMagistrateJudge. *z    E.` hp x '#` ` XE  E.` ` ` hp x (#X'#E_(c)_ ` Isthereanythinginyourpersonalorprofessionalbackgroundthat,ifpublicly &v known,couldbeviewedasembarrassingeithertoyoupersonallyortothiscourt?  \   E.` hp x '#` ` XEYes____No____.Ifyes,giveparticulars.  ( 20 ThisapplicationisfortheUnitedStatesMagistrateJudgepositionat:    hE.` hp x (#X'#E  ! XX!Brooklyn0 CentralIslip h EitherCourtLocation| (# (#   hB.` hp x '#XB(Pleaseselectoneoption) H ̄% 4 %4kpԄIdeclareunderpenaltyofperjurythatIcompletedtheforegoingfourteen(14)pageapplication    withtheattachments,andthatitcontainstrueandcorrectinformation.    Executedon: x  Date:_______________________________ D   X `  XSignatureofCandidate:  __________________________________________ F  f&     f&  ConfidentialityStatement    Theindividualswhomyouhavelistedasreferencesin#40abovemaybecontactedbythePanel, | butnootheremployers,colleaguesorotherswillbecontactedwithoutyourpriorapproval.The b _AWaiver_ԀofConfidentiality@willnotbeusedwithoutyourpriorapproval. H   HowToApply  d  X  Theoriginalplustherequiredcopiesofthecompleteapplication(withallappendices)  0 mustbereceivedbyClerkofCourt,225CadmanPlazaEast,Brooklyn,NewYork11201,not    laterthanthedatespecifiedinthePublicNotice.     X XYouareinvitedtoappend: x   X XB+ ` hp x '#X'#B1. ` Aonepagecurriculumvitae. D    XE.` ` ` hp x (#X'#E2. ` Aonepagestatementon(A)whatyoubelievethedutiesofaU.S.Magistrate *z  Judgetobe,and,(B)howyourqualificationsandbackgroundqualifyyouto ` assumesuchduties. F   E.` hp x '#` ` XE N.B. Ifyouchangeyouraddressorifanythingoccurswhichwouldaffectyouranswerstothis  application,noticeofsuchchangeshouldbesenttotheChairmanoftheMeritSelectionPanel.   52   WAIVEROFCONFIDENTIALITY   X  TheMeritSelectionPanelhascompleteditsinitialscreeningofapplicantsforthe b positionofUnitedStatesMagistrateJudge.Wearenowinneedofadditionalinformationon H yourbackgroundandqualificationstodeterminewhethertorecommendyoutotheDistrict . ~ CourtforappointmentasaMagistrateJudge.Accordingly,werequestyourapprovaltoconsult  d withyourcurrentorpastemployersorcolleagues,andotherindividualswhohavematerial  J knowledgeofyourqualifications(includingyourphysician)inordertoverifyandtosupplement  0 theinformationcontainedinyourapplicationform.A_Awaiver_Ԁofconfidentiality@isprinted    immediatelybelowforthispurpose.     X  Waiver ^   X  Iherebyauthorizethecustodianofanyrecordsorinformationtopermittheexamination ` orreceiptofsuchinformation,whetherwrittenororal,bytheMeritSelectionPanel.Ialso F authorizetheMeritSelectionPaneltoconsultwithmyformeremployers,myprofessional , colleagues,andmyphysicianwithregardtomatterspertinenttomyqualificationsforthe  positionofaUnitedStatesMagistrateJudge.   XDate:______________________ &v Signature:_______________________________________ (