Managed Assigned Counsel Application Use this form to make your initial application to a Managed Assigned Counsel Roster (MAC Roster). Name(Required) First Middle Last Licensure(Required)MAC program contracts are only available to attorneys currently licensed to practice law in North Carolina. I am licensed to practice law in North Carolina Year Licensed(Required)20222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719561985198419831982198119801979197819771976197519741973197219711970State Bar Number(Required)Firm or Employer Name Use "self" if self-employedAddress(Required) Street Address Address Line 2 City ZIP / Postal Code Email(Required) Cell Phone(Required)Office PhoneHave you ever been subject to public discipline of any level issued by the Grievance Committee of the State Bar or the Disciplinary Hearing Commission; a judicial finding of misconduct or ineffective assistance of counsel; made a formal admission by counsel of ineffective assistance; or had criminal charges filed against you? Yes No If you answered yes to the preceding question, please describe the proceeding below including the forum, file number, and resolution.I would like to apply for the following MAC Rosters:(Required) List 1: Misdemeanor Cases and Misdemeanor Probation Violations List 2: Felonies E through I and Superior Court Probation Violations List 3: Felonies A through D Select AllI would like to apply to the selected adult criminal rosters in the following counties:(Required) Alamance Caswell Durham Chatham Franklin Granville Greene Harnett Johnson Lee Lenoir Orange Person Pitt Vance Wake Warren Wayne Preferred Counties and RostersIf you applied to more than one county and more than one roster, please rank them in order of preference here. For example, Durham, List 1; Durham, List 4, etc. Use the "+" icon for additional fields. Add RemoveI have practiced adult criminal law on a consistent basis for ____ years.(Required)Please indicate the number of years you have practiced criminal law. I have attended the below continuing legal education (“CLE”) programs within the past year (specify date(s), program(s), and sponsor(s) below) within the last year:It is important that you list all criminal defense related CLE you attended within the last year. In some cases, IDS may waive required jury trial or years of practice. For example, IDS may allow an attorney who has attended 3 hours of criminal defense CLE but has less than 1 year of experience on the misdemeanor roster. In other cases, IDS may waive some jury trial experience if the applicant has at least 12 hours of criminal defense related CLE. Use "+" icon to the right of date to add additional fields. DateProgramSponsorHours Add RemovePlease describe your criminal defense trial experience.Use this space to describe your experience in criminal law including how many bench trials you have had or observed. If you are applying for a felony contract, please describe the number of jury trials you have conducted, whether you served as first or second chair, and whether the trials went to verdict. Request for Waiver I am requesting a waiver and agree to the following:I acknowledge that I do not meet the minimum qualifications for the list(s) to which I have applied. I understand that IDS may still elect to enter into a MAC contract with me but that the contract may include additional requirements as deemed appropriate by IDS. AttachmentsYou may attach document here that you think will aid IDS in its evaluation of this application. Maximum number of attachments is 4. FileMax. file size: 50 MB.FileMax. file size: 50 MB.FileMax. file size: 50 MB.FileMax. file size: 50 MB.Acknowledgment(Required) I agree to the following:I the undersigned, certify that I have given true, accurate, and complete information on this application to the best of my knowledge. I authorize Indigent Defense Services to investigate all information provided in this application and supporting submissions. I understand that false information, false documentation, or a failure to disclose relevant information may be grounds for rejection of my application. I consent to a confidential inquiry by Indigent Defense Services of the contacts listed in this application, if any, and others familiar with my competence, for the purpose of determining whether I fulfill the requirements to be placed on the roster of attorneys eligible for appointment for the lists on which I have requested placement. I further understand that all information received by Indigent Defense Services in conjunction with this application, including reference information, shall be confidential and available for use only by Indigent Defense Services and shall not be disclosed except as required by law. By submitting this application, I explicitly waive the right to review reference information obtained by IDS. I have read the Regulations for Appointment of Contract Counsel in Cases under the Indigent Defense Services Act, and I agree to abide by the rules and conditions of appointment set forth there. Signature(Required) Reset signature Signature locked. Reset to sign again Untitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice Untitled Managed Assigned Counsel Application Use this form to make your initial application to a Managed Assigned Counsel Roster (MAC Roster). Name(Required) First Middle Last Licensure(Required)MAC program contracts are only available to attorneys currently licensed to practice law in North Carolina. I am licensed to practice law in North Carolina Year Licensed(Required)20222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719561985198419831982198119801979197819771976197519741973197219711970State Bar Number(Required)Firm or Employer Name Use "self" if self-employedAddress(Required) Street Address Address Line 2 City ZIP / Postal Code Email(Required) Cell Phone(Required)Office PhoneHave you ever been subject to public discipline of any level issued by the Grievance Committee of the State Bar or the Disciplinary Hearing Commission; a judicial finding of misconduct or ineffective assistance of counsel; made a formal admission by counsel of ineffective assistance; or had criminal charges filed against you? Yes No If you answered yes to the preceding question, please describe the proceeding below including the forum, file number, and resolution.I would like to apply for the following MAC Rosters:(Required) List 1: Misdemeanor Cases and Misdemeanor Probation Violations List 2: Felonies E through I and Superior Court Probation Violations List 3: Felonies A through D Select AllI would like to apply to the selected adult criminal rosters in the following counties:(Required) Alamance Caswell Durham Chatham Franklin Granville Greene Harnett Johnson Lee Lenoir Orange Person Pitt Vance Wake Warren Wayne Preferred Counties and RostersIf you applied to more than one county and more than one roster, please rank them in order of preference here. For example, Durham, List 1; Durham, List 4, etc. Use the "+" icon for additional fields. Add RemoveI have practiced adult criminal law on a consistent basis for ____ years.(Required)Please indicate the number of years you have practiced criminal law. I have attended the below continuing legal education (“CLE”) programs within the past year (specify date(s), program(s), and sponsor(s) below) within the last year:It is important that you list all criminal defense related CLE you attended within the last year. In some cases, IDS may waive required jury trial or years of practice. For example, IDS may allow an attorney who has attended 3 hours of criminal defense CLE but has less than 1 year of experience on the misdemeanor roster. In other cases, IDS may waive some jury trial experience if the applicant has at least 12 hours of criminal defense related CLE. Use "+" icon to the right of date to add additional fields. DateProgramSponsorHours Add RemovePlease describe your criminal defense trial experience.Use this space to describe your experience in criminal law including how many bench trials you have had or observed. If you are applying for a felony contract, please describe the number of jury trials you have conducted, whether you served as first or second chair, and whether the trials went to verdict. Request for Waiver I am requesting a waiver and agree to the following:I acknowledge that I do not meet the minimum qualifications for the list(s) to which I have applied. I understand that IDS may still elect to enter into a MAC contract with me but that the contract may include additional requirements as deemed appropriate by IDS. AttachmentsYou may attach document here that you think will aid IDS in its evaluation of this application. Maximum number of attachments is 4. FileMax. file size: 50 MB.FileMax. file size: 50 MB.FileMax. file size: 50 MB.FileMax. file size: 50 MB.Acknowledgment(Required) I agree to the following:I the undersigned, certify that I have given true, accurate, and complete information on this application to the best of my knowledge. I authorize Indigent Defense Services to investigate all information provided in this application and supporting submissions. I understand that false information, false documentation, or a failure to disclose relevant information may be grounds for rejection of my application. I consent to a confidential inquiry by Indigent Defense Services of the contacts listed in this application, if any, and others familiar with my competence, for the purpose of determining whether I fulfill the requirements to be placed on the roster of attorneys eligible for appointment for the lists on which I have requested placement. I further understand that all information received by Indigent Defense Services in conjunction with this application, including reference information, shall be confidential and available for use only by Indigent Defense Services and shall not be disclosed except as required by law. By submitting this application, I explicitly waive the right to review reference information obtained by IDS. I have read the Regulations for Appointment of Contract Counsel in Cases under the Indigent Defense Services Act, and I agree to abide by the rules and conditions of appointment set forth there. Signature(Required) Reset signature Signature locked. Reset to sign again Untitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice Untitled
