Application to Serve as Assigned Counsel

Contact Information

Name *

Business Address *

E-Mail Address *

Phone *

Fax

Registration

Admitted to Ohio Bar *

Registration Number *

What are the years for your biennial registration? *

Certifications

I reviewed the qualifications in L.R. 33 and certify that I am qualified to provide representation for the following (check all that apply):

Lead Counsel: APPT. COUN. R. 3.02/Death Penalty

Co-Counsel: APPT. COUN. R. 3.03/Death Penalty

Life Sentence

Felony 1st/2nd Degree without life sentences

Felony 3rd Degree without life sentences

Felony 4th/5th Degree and unspecified felonies other than murder

OVI Felony (I have obtained 6 hours of CLE in OVI practice & procedure for the most current reporting period)

Mental Health Docket (I have completed the Court's mental health training seminar)

Probation Violation Hearing

Cases

I have served as trial counsel in the following cases which were tried to verdict. Include Docket Number, Defendant Name, Highest Charge, Date of Trial, Court or Jury Trial, Judge for each case, Lead or Assistant. Complete for intital application / redesignation or reinstatement, if applicable (Not required for renewal)

Case 1

Case 2

Case 3

Case 4

Case 5

Confirmation

I certify the following. By doing so, I acknowledge that all of the information I am providing is correct and truthful: *

Attachment: Proof of Insurance

Attachment: Most recent CLE transcript for criminal practice and procedure

I have other relevant qualifications for consideration. (please attach here)