Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 1 of 20
To the Appellate Division of the Supreme Court of the State of New York: The undersigned hereby applies for
admission to practice as an attorney and counselor-at-law in all courts of the State of New York, and in support of such
application submits the following sworn statement and the accompanying affidavits and other papers.
A. Personal Information
1. State name in full:
First Name Middle Name
Last Name Suffix (Jr., III)
2. Have you ever used or been known by any other name? No Yes
If ‘Yes’, state in full each name (other than the name given above) which you have used or by which you have at any
time been known, and the reason for the change, including the period of the use of such name; if change of name is
by marriage so state; if change of name was by court order so state.
Full Name Reason for change
Full Name Reason for change
3. United States Social Security number (if any):
4. BOLE ID# (NYS Board of Law Examiners Identication Number): B
5. State the following: Age: Date of Birth (mm/dd/yyyy):
Place of Birth (City/Town/Village) State Country
6. Present residence (full mailing address):
Street Address
City/Town/Village State ZIP Country (if not USA)
Telephone E-mail (if any)
Application For (check one)
Admission on Examination or
Admission on Motion without Examination
Appellate Division (check one)
1st Dept.
2nd Dept.
3rd Dept.
4th Dept.
Pro Bono Scholars Program
Application for Admission Questionnaire - Please see the General Instructions for guidance on filing complete applications
Application for Admission to Practice as an Attorney and
Counselor-at-Law in the State of New York
New York State Supreme Court Appellate Division
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 2 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
7. Prior residence (provide the last permanent residence where you resided before the address in question 6):
Period From (mm/yyyy): To (mm/yyyy):
Street Address
City/Town/Village State ZIP Country (if not USA)
8. Office address (if applicable):
Name of Office and Street Address
City/Town/Village State ZIP Country (if not USA)
Telephone E-mail (if any)
B. Education
9. List all colleges, universities and professional schools (other than law schools) attended. Provide a chronological
listing (from earliest to latest). If you did not receive a degree, state the reason.
Dates of Attendance From (mm/yyyy): To (mm/yyyy):
Name of College / University / Other Degree
Street Address City/Town/Village
State ZIP Country (if not USA)
Reason for not receiving a degree (if applicable)
Dates of Attendance From (mm/yyyy): To (mm/yyyy):
Name of College / University / Other Degree
Street Address City/Town/Village
State ZIP Country (if not USA)
Reason for not receiving a degree (if applicable)
Dates of Attendance From (mm/yyyy): To (mm/yyyy):
Name of College / University / Other Degree
Street Address City/Town/Village
State ZIP Country (if not USA)
Reason for not receiving a degree (if applicable)
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 3 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
10. List all law schools attended. Provide a chronological listing (from earliest to latest). If you did not receive a degree,
state the reason.
Form Law School Certicates: You must send the Form Law School Certicate to each law school listed
below. Each law school should return the form directly to the Appellate Division.
Dates of Attendance From (mm/yyyy): To (mm/yyyy):
Name of Law School Degree
Street Address City/Town/Village
State ZIP Country (if not USA)
Reason for not receiving a degree (if applicable)
Dates of Attendance From (mm/yyyy): To (mm/yyyy):
Name of Law School Degree
Street Address City/Town/Village
State ZIP Country (if not USA)
Reason for not receiving a degree (if applicable)
Note: If you answer ‘Yes’ to question 11, 12 or 13, give the name of the institution, and state fully the
circumstances and date of each such occurrence.
11. Have you ever been denied admission to any school, college, law school, or other similar institution for stated cause
which might reect upon your character?
No Yes (if “Yes” answer below)
Name of Institution Date (mm/yyyy)
Reason and Circumstances:
12. Have you ever been placed on probation, dropped, suspended, expelled or otherwise been subjected to discipline
by any institution of learning above elementary school level for conduct which might reect upon your character?
No Yes (if “Yes” answer below)
Name of Institution Date (mm/yyyy)
Reason and Circumstances:
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 4 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
13. Have you ever been requested or advised by any college, law school, or other professional or graduate school for
any reason to discontinue your studies therein?
No Yes (if “Yes” answer below)
Name of Institution Date (mm/yyyy)
Reason and Circumstances:
C. Employment
14. List every employment you have had since you reached the age of 21, or in the last 10 years, whichever period
is shorter, in chronological order (from earliest to latest). Include your current employment, if any. Include self-
employment, clerkships, temporary or part-time employment, military service, employment by members of family or
other relatives, employment with or without monetary compensation, law-related work-study employment, and law-
related employment for academic credit only, including participation in law school clinics and externships, and work as
a research assistant. Note to applicants applying for admission on examination: do not include employments listed on
your 50 hour pro bono compliance affidavit or listed on your pro bono scholars program completion affidavit.
Form Affirmations as to Applicant’s Law-Related Employment and/or Solo Practice: For each law-
related employment or period of solo law practice listed in reply to this question, please submit an original form
affirmation. If you have not had any law-related employment, submit a letter addressed to the Appellate Division
on the letterhead of your present employer, or if you are not presently employed, from your last employer, giving
(a) the nature of the services you rendered, (b) the period of employment, (c) the reason you left, and (d) a
brief evaluation of your character. Note to applicants applying for admission on examination: do not submit an
employment affirmation for employments listed on your 50 hour pro bono compliance affidavit or listed on your
pro bono scholars program completion affidavit.
Period From (mm/yyyy) Period To (mm/yyyy)
Name of Employer Position(s) Held
Employer’s Address City/Town/Village
State ZIP Country (if not USA)
Telephone Nature of Employer’s Business
Reason for Leaving or Termination:
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 5 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
Period From (mm/yyyy) Period To (mm/yyyy)
Name of Employer Position(s) Held
Employer’s Address City/Town/Village
State ZIP Country (if not USA)
Telephone Nature of Employer’s Business
Reason for Leaving or Termination:
Period From (mm/yyyy) Period To (mm/yyyy)
Name of Employer Position(s) Held
Employer’s Address City/Town/Village
State ZIP Country (if not USA)
Telephone Nature of Employer’s Business
Reason for Leaving or Termination:
Period From (mm/yyyy) Period To (mm/yyyy)
Name of Employer Position(s) Held
Employer’s Address City/Town/Village
State ZIP Country (if not USA)
Telephone Nature of Employer’s Business
Reason for Leaving or Termination:
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 6 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
Period From (mm/yyyy) Period To (mm/yyyy)
Name of Employer Position(s) Held
Employer’s Address City/Town/Village
State ZIP Country (if not USA)
Telephone Nature of Employer’s Business
Reason for Leaving or Termination:
Period From (mm/yyyy) Period To (mm/yyyy)
Name of Employer Position(s) Held
Employer’s Address City/Town/Village
State ZIP Country (if not USA)
Telephone Nature of Employer’s Business
Reason for Leaving or Termination:
15. Are you now, or have you ever been, engaged on your own account or with others in any occupation, business
enterprise, or profession (other than law and not included in question 14) in the State of New York or elsewhere?
No Yes
If ‘Yes’, give in detail the nature and location thereof and the month and year of the beginning and ending of your
engagement in or connection therewith. If any such business was carried on by you in partnership with others, give the
names and addresses of all partners and the nature of the business. If the business was carried on by a corporation in
which you held any office, state its name and address, the nature of its business and your connection with it.
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 7 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
List any action now pending against such rm or corporation and any judgment entered against it during the period
of your association with it.
16. In connection with any employment, whether or not listed in question 14, have you ever been discharged or
requested to resign from or leave your position for cause?
No Yes
If ‘Yes’, give the name of each such employer and state the date and circumstances as to each such incident.
D. Bar Admissions and Other Registrations/Licenses
17. Have you ever applied for admission to the Bar of the State of New York in this or any other Department (see CPLR
§ 9405), including admission pro hac vice (see 22 NYCRR 520.11) or for registration as in-house counsel, or for
license as a foreign legal consultant in this State (see 22 NYCRR Parts 521 and 522)?
No Yes
If ‘Yes’, explain (with dates and disposition).
18. Have you ever applied to take or taken the Bar examination in any country, state or jurisdiction other than the State
of New York?
No Yes
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 8 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
19. Have you ever applied for admission to practice as an attorney in any country, state or jurisdiction other than the
State of New York?
No Yes
If your answer to questions 18 or 19 is ‘Yes’, state specically the result of the Bar examination and/or the disposition
made of the application. If admitted, state the name of each jurisdiction and court by which admitted and the date of
such admission. Do not include applications to United States federal courts in your response.
Applicants Admitted in Other States or Countries Must Submit: (1) an original certicate of good standing at
the Bar from each such jurisdiction and (2) an original letter from each such jurisdiction’s grievance committee,
or other body entertaining complaints against lawyers, where available, certifying as to whether charges have
ever been led with such committee or body against you, and, if so, the substance of the charges and the
disposition thereof. Certicates of good standing and grievance letters should not be dated more than 60 days
prior to submission. You do not need to submit certicates or letters from any United States federal court in
which you have been admitted to practice.
20. Have you ever engaged in or has your conduct ever been called into question with reference to the unauthorized
practice of law?
No Yes (if “Yes” explain)
21. Have you ever been employed by or otherwise connected with any person, rm or corporation who or which, to your
knowledge, engaged in conduct that was called into question on the subject of unauthorized practice of law while
you were so employed or connected?
No Yes (if “Yes” explain)
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 9 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
22. Except for activities comprising part of a law school clinical program or otherwise permitted by law (see Judiciary
Law §§ 478, 484, 495), have you ever tried any action or proceeding, argued any motion, drawn legal papers other
than under the supervision of an attorney, given legal advice or held yourself out as an attorney in this State?
No Yes (if “Yes” explain)
E. Military Record
Please answer both questions 23 and 24.
23. Have you at any time or in any manner served in any of the armed forces of the United States, including reserves?
No Yes (if “Yes” answer below)
Period Served From (mm/yyyy) Period Served To (mm/yyyy)
Where Branch of Service
Nature of Service Rendered:
If Discharged: Give Date And Nature Of Discharge:
24. Have you served in the armed forces (reserves or otherwise) of any country other than the United States of America?
No Yes (if “Yes” answer below)
Period Served From (mm/yyyy) Period Served To (mm/yyyy)
Where Branch of Service
Nature of Service Rendered:
If Discharged: Give Date And Nature Of Discharge:
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 10 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
25. Note: Answer only if you answered ‘Yes’ to questions 23 or 24. As a member of any armed forces, have you been
the subject of any charge, or have any proceedings been instituted against you, or have you been a defendant in
any court martial proceeding?
No Yes (if “Yes” state the facts below)
F. Interactions with Law Enforcement
The Appellate Division of the Supreme Court and its Committee on Character and Fitness have a statutorily imposed
obligation to carefully investigate the character and tness of every applicant seeking admission to the practice of law
in New York (see CPLR 9404; Judiciary Law § 90 [1] [a]; Rules of App Div, 1st Dept [22 NYCRR] § 636.10; Rules of
App Div, 2d Dept [22 NYCRR] § 711.3; Rules of App Div, 3d Dept [22 NYCRR] § 840.5; Rules of App Div, 4th Dept [22
NYCRR] § 1040.1). The information requested here is considered in furtherance of that obligation; like all information
disclosed in this application, it is treated condentially (see Judiciary Law § 90 [10]).
The mere fact that an applicant’s past includes interactions with law enforcement is not, by itself, a basis on which an
applicant is denied admission. Nevertheless, the burden of proving that an applicant possesses the requisite character
and tness to practice law is borne by the applicant. Please provide a statement setting forth the facts underlying any
incident disclosed here; if police and court records are deemed necessary following review of your application, they will
be requested at that time.
26. Are you a defendant in a pending criminal matter, or have you, at any age, unless specically excluded below, been
charged with, indicted for, tried for, convicted of, or pleaded guilty to, any felony or misdemeanor or the violation of
any law? In your response to this question, disclose any matter in which you were adjudicated a youthful offender or
received an equivalent adjudication in another jurisdiction.
Do NOT report:
(a) any matter in which you were adjudicated a juvenile delinquent in Family Court or other noncriminal proceeding;
(b) any citation, ticket or arrest that did not result in criminal charges or an indictment, trial, conviction or guilty plea;
(c) vehicle and traffic matters that occurred more than 10 years before the ling of this application, EXCEPT alcohol
or drug-related traffic violations, which must be reported in all cases, irrespective of when they occurred; or
(d) parking violations.
No Yes (if “Yes” answer below)
Name and Locality of Court Charge or Charges
Disposition Thereof and Underlying Facts, Including Relevant Dates:
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 11 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
G. Civil Matters
27. State whether you have ever testied, refused to testify, or been granted immunity, as a complainant, party or
witness in any action or proceeding, or before any prosecuting or investigative agency in any matter.
No Yes
28. State whether you have ever failed to answer any ticket, summons or other legal process served upon you at any time.
No Yes
29. If you answered ‘Yes’ to question 28, was any warrant, subpoena or further process issued against you as a result
of your failure to respond to such legal process?
No Yes
30. State whether there are any unpaid traffic or parking tickets in your name or attributable to a motor vehicle
registered in your name; if ‘Yes’, please complete the following.
No Yes
Description of unpaid ticket(s) Fines - Amount(s) due and Date(s) due
31. State whether you have ever been charged with fraudulent conduct or any other act involving moral turpitude.
No Yes
32. State whether you have ever been a complainant, party or witness to or otherwise involved in any civil or criminal
action, proceeding or investigation not covered by answers to the above questions 27-31.
No Yes
If you answered ‘Yes’ to any of the above questions 27-32, indicate the question and state the facts as fully as
possible. If applicable, provide the name and locality of the court or agency, the approximate date of the action or
proceeding, and the judgment or other disposition.
H. Conduct Relevant to Fitness to Practice
The Appellate Division of the Supreme Court and its Committees on Character and Fitness have a statutorily imposed
obligation to carefully investigate the character and tness of every applicant seeking admission to the practice of law in
New York (see CPLR 9404; Judiciary Law § 90 [1] [a]). The information requested here is considered in furtherance of
that obligation; like all information disclosed in this application, it is treated condentially (see Judiciary Law § 90[10]).
This section requires full and candid disclosure of conduct and behavior that may call into question your ability to practice
law in a competent, ethical or professional manner. While an applicant may be denied admission when the applicant’s
ability to function is impaired in a manner relevant to the tness to practice law, past or present treatment for a condition
or impairment is viewed favorably by the Appellate Division of the Supreme Court and its Committees on Character and
Fitness. Indeed, applicants who may benet from treatment are encouraged to seek it.
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 12 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
33. Within the past seven 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?
No Yes
If your answer is ‘Yes’, furnish the following information.
Name of Entity Before Which the Issue was Raised (i.e., Court, Agency, Etc.)
Street Address City/Town/Village State
ZIP Country Province Telephone
Nature of the Proceeding Relevant Date(s)
Disposition, if any
Explanation:
34. Except as otherwise disclosed on this application, within the past seven years, have you engaged in any conduct or
behavior that, as applied to you:
(a) resulted in an arrest, discipline, sanction or warning;
(b) resulted in termination or suspension from school or employment;
(c) resulted in loss or suspension of any license;
(d) resulted in any inquiry, any investigation, or any administrative or judicial proceeding by an employer,
educational institution, government agency, professional organization, or licensing authority, or in connection
with an employment disciplinary or termination procedure;
(e) endangered the safety of others, breached duciary obligations, or constituted a violation of workplace or
academic conduct rules; or
(f) resulted in your involuntary hospitalization by court order?
No Yes
If so, provide a complete explanation and include all defenses or claims that you offered in mitigation or as an
Name of Entity Before Which the Issue was Raised (i.e., Court, Agency, Etc.)
Street Address City/Town/Village State
ZIP Country Province Telephone
Nature of the Proceeding Relevant Date(s)
Disposition, if any
Explanation:
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 13 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
35. Except as otherwise disclosed in this application, within the past seven years, have you exhibited or engaged in
any conduct or behavior, including conduct or behavior resulting from a condition or impairment, that could call into
question your ability to practice law in a competent, ethical, and professional manner?
No Yes
Relevant Date(s)
Explanation:
36. Are you currently using any illegal drugs?
No Yes
I. Child Support
37. As of the date this application is led, state whether you are or are not under an obligation to pay child support.
I Am I Am Not
If you answered ‘I Am’, answer the following questions:
(a) Are you four months or more in arrears in the payment of child support?
No Yes
(b) Are you making payments by income execution or by court agreed payment or repayment plan or by plan
agreed to by the parties?
No Yes
(c) Is the child support obligation the subject of a pending court proceeding?
No Yes
(d) Are you receiving public assistance or supplemental security income?
No Yes
PLEASE NOTE THAT PERSONS WHO ARE FOUR MONTHS OR MORE IN ARREARS IN CHILD
SUPPORT OR WHO HAVE FAILED TO COMPLY WITH A SUMMONS, SUBPOENA OR WARRANT
RELATING TO A PATERNITY OR CHILD SUPPORT PROCEEDING MAY BE SUBJECT TO SUSPENSION
OF THEIR BUSINESS, PROFESSIONAL, DRIVER’S AND/OR RECREATIONAL LICENSES AND
PERMITS INCLUDING, BUT NOT LIMITED TO, LICENSES ISSUED PURSUANT TO ENVIRONMENTAL
CONSERVATION LAW § 11-0713.
Please further note that the intentional submission of false written statements for the purpose of
frustrating or defeating the lawful enforcement of support obligations is punishable pursuant to section
175.35 of the Penal Law of the State of New York.
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 14 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
J. Financial Matters / Defaults
38. Are there any unsatised judgments against you?
No Yes
If ‘Yes’, list the same giving the name and address of the judgment creditor and the court by which judgment was
made, together with the date and amount thereof and the nature of the claim on which it was based.
Judgment Creditor Name Judgment Creditor Address
Court Date (mm/dd/yyyy) Amount
Nature of Claim:
39. Are you in default in the performance or discharge of any duty or obligation imposed upon you by a judgment,
decree, order or directive of any court or governmental agency?
No Yes
If ‘Yes’, state the facts.
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 15 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
40. Do you owe any debt for $300 or more, which is past due for over 90 days?
No Yes
If ‘Yes’, list each such debt and state the name and address of the creditor, the amount presently owed, the due
date, and the nature of the debt.
Creditor Name
Creditor Address
Amount Owed Date (mm/dd/yyyy)
Nature of Debt:
Creditor Name
Creditor Address
Amount Owed Date (mm/dd/yyyy)
Nature of Debt:
Creditor Name
Creditor Address
Amount Owed Date (mm/dd/yyyy)
Nature of Debt:
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 16 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
41. Have you ever applied for or been granted a discharge in bankruptcy?
No Yes
If ‘Yes’, briey state the facts, including the reason for bankruptcy, date of petition, date of discharge or other
disposition and court.
K. Licenses / Bonds
Please answer both questions 42 and 43.
42. (a) Have you ever applied for a license the procurement of which required proof of good character (other than Bar
applications listed under question 17–19 above)?
No Yes
If granted, state, as to each such license, the approximate date it was granted and the name of the authority
granting it.
License(s) Date(s) Granted (mm/yyyy) Name(s) of Authority
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 17 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
(b) If your application for such a license was not granted, state the facts.
(c) If any such license was revoked or suspended, state the facts.
43. Has anyone ever sought to recover on or cancel a delity bond on account of your conduct in connection with a
bonded position held by you?
No Yes
If ‘Yes’, specify the nature of your position, the dates during which you were bonded, and the underlying
circumstances.
Position
Date Bonded From (mm/yyyy) Date Bonded To (mm/yyyy)
Underlying Circumstances:
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 18 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
L. Loyalty / Oaths / Rules of Professional Conduct
44. Have you ever organized or helped to organize or become a member of any organization or group of persons which,
during the period of your membership or association, you knew was advocating or teaching that the government
of the United States or any state or any political subdivision thereof should be overthrown or overturned by force,
violence or any unlawful means?
No Yes
If ‘Yes’, state the facts.
45. Please read carefully: I hereby state that I can take and subscribe to an oath or affirmation that I will support the
Constitutions of the United States and the State of New York.
I hereby conscientiously affirm that I am, without any mental reservation, loyal to and ready to support the
Constitutions of the United States and the State of New York.
I have read and I will conscientiously endeavor to conform my professional conduct to the Rules of Professional
Conduct adopted by the Appellate Division (see 22 NYCRR Part 1200).
If you cannot so state, affirm and or endeavor, please explain.
SINCE THIS IS A CONTINUING APPLICATION, I WILL SUBMIT SUCH ADDITIONAL AFFIDAVITS,
AFFIRMATIONS, PAPERS OR INFORMATION AS MAY BE REQUESTED OR AS MAY BE NECESSITATED
BY ANY CHANGE IN MY SITUATION UP TO THE DATE OF MY APPEARANCE BEFORE THE APPELLATE
DIVISION TO BE SWORN IN AS AN ATTORNEY AND COUNSELOR-AT-LAW.
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 19 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
This Application for Admission Questionnaire Must Be Signed and Notarized as Indicated Below.
STATE (COUNTRY) OF
COUNTY OF
CITY OF
I (name of applicant), , SWEAR (OR AFFIRM) THAT:
I have read the foregoing questions and have fully, truthfully and accurately answered the same. The
foregoing answers are true of my own knowledge, except if stated to be made upon information and belief, and
as to such answers, I believe them to be true.
I authorize the Appellate Division of the Supreme Court and its Committees on Character and Fitness to
investigate my character and general tness to practice law and to contact individuals and entities listed in this
Application for Admission for the purpose of ascertaining my character and tness to practice law. I further
authorize such individuals and entities to communicate with the Appellate Division of the Supreme Court and its
Committees on Character and Fitness in this regard to provide such clarication and/or further information and
documentation as they require.
I hereby release, discharge, and exonerate the Appellate Division of the Supreme Court and its Committees
on Character and Fitness, their members, agents and representatives, as well as any person furnishing
information to the committee from any and all liability of every nature and kind in the course of their duties
arising out of the investigation made by the Appellate Division into my moral character, professional reputation,
and general tness for the practice of law, including, without limitation, the inspection of documents, records,
and other information related to my treatment for any mental health, drug, alcohol or other substance related
condition, or any addiction.
Signature of Applicant
Dated (mm/dd/yyyy)
Subscribed and sworn to or affirmed before me this
day of in the year 20 .
Notary Public*
(Sign & Affix seal or stamp)
* If application questionnaire is sworn to outside the United States, its commonwealths, territories, or possessions, and the attesting officer is not a notary
public, attach a certicate of the attesting officer’s authority to attest to or witness the signature of the affiant in the jurisdiction.
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Application for Admission Questionnaire (04/2023) Page 20 of 20
Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York
Application for Admission Questionnaire (Continued) - Please see the General Instructions for guidance on filing complete applications
ADDENDUM: DESIGNATION OF AGENT
This designation must be completed only by applicants who do not reside and are not employed full time in the State of
New York (see 22 NYCRR 520.13).
I (name of applicant), , do hereby appoint the
Clerk of the Appellate Division, Judicial Department,* as my agent upon whom
process may be served with like effect as if served upon me personally, in any action or proceeding hereafter
brought against me and arising out of or based upon any legal services rendered or offered to be rendered by
the undersigned in the State of New York.
Signature of Applicant
Dated (mm/dd/yyyy)
STATE (COUNTRY) OF
COUNTY OF
CITY OF
On the day of in the year 20 before me, the undersigned,
personally appeared , personally known to me or proved to me on the basis of
satisfactory evidence to be the individual whose name is subscribed to the above designation of agent and
acknowledged to me that he or she executed the same, and that by his or her signature on the designation of
agent he or she executed the designation of agent.
Officer qualied to administer oath
(Notary Public)**
(Sign & Affix seal or stamp)
* Enter the Appellate Division Department in which you are being licensed.
** If designation of agent is sworn to outside the United States, its commonwealths, territories, or possessions, and the attesting officer is not a notary
public, attach a certicate of the attesting officer’s authority to attest to or witness the signature of the affiant in the jurisdiction.
