Comity Application

PERSONAL INFORMATION

Applicant Information

Full name

Firm name (if business)

Street Address Line 1

Street Address Line 2

City

State or Province

Zip or postal code

Country

E-mail address

Mobile phone number

Social Security Number

Date of birth

Age

Place of birth

In what country are you a citizen?

Parent 1’s Name and Address

Parent 1’s Name and Address

First Name

Last Name

Is Parent 1 deceased?

Address 1

Address 2

City

State

ZIP Code

Country

Parent 2’s Name and Address

Parent 2’s Name and Address

First Name

Last Name

Is Parent 2 deceased?

Address 1

Address 2

City

State

ZIP Code

Country

Driver's Licenses

Current driver’s license (State and Number) and all driver's licenses previously held in other states.

Please upload a driving record from the Department of Motor Vehicles of each state in which you have ever been licensed to drive.

Do you have a driver's license?

From mo/yr

To mo/yr

Driver's License Number

Driver's License State, Province or Country

Name Change

Have you ever used or been known by any other name?

If YES, please state in full, each name used or by which you have at any time been known and the reasons for each such name.

If your name has been changed, please state former name and when, how and why change was made. If change was made in a proceeding, please annex a copy of the order or other appropriate evidence of change.

From Mo/Yr

To Mo/Yr

Name

	Explanation

APPLICATIONS, AUTHORIZATIONS AND CONDUCT

Comity Jurisdiction

Which reciprocal jurisdiction(s) are you relying upon for admission in North Carolina by comity?

Jurisdiction 1

Jurisdiction 2

Jurisdiction 3

Jurisdiction 4

	Please provide a detailed description of the nature of your practice in the jurisdiction(s) listed above.

State Bar Admissions

Have you ever submitted, or are currently submitting, to take a State bar examination or an attorney’s examination or application for admission to practice law, or to practice before an administrative agency in any state, jurisdiction, or country? This includes any prior application for admission in North Carolina. This must include your admission in a reciprocal jurisdiction, which qualifies you for admission by comity.

State*

Exam Date

Successful?

By Motion

Admitted Yes/No

Admitted Date

Bar Number

If not admitted or approved, indicate reason:

*IF ADMITTED IN NEW YORK, INDICATE WHICH DEPARTMENT.

Please upload a copy of each prior application (this does not include those applications previously filed in North Carolina.) If a copy of a prior application is unavailable please ensure the Jurisdiction provides the Board a letter stating this information is no longer available.

State Bar Admissions Withdrawal

Have you ever withdrawn an application for admission to the bar of any jurisdiction?

If YES, indicate:

Jurisdiction

Date of application

Date of withdrawal

Reason for withdrawal

Board Appearances

In any of the above jurisdictions and courts including North Carolina were you required to appear before any board committee or other examining authority for inquiry about any matter, other than examination upon legal subjects, in connection with your application for admission to practice law?

If YES, list the jurisdiction(s), the name and complete mailing address of any such authority and describe the circumstances surrounding each incident.

Name of jurisdiction

Mailing address

	Describe the circumstances

Denied Applications

Have you ever made application in any of the above jurisdictions and courts including North Carolina which application was denied?

If YES, list the jurisdiction(s), the name and complete mailing address of any such authority and describe the circumstances surrounding each incident.

Name of jurisdiction

Mailing address

	Describe the circumstances

Court Admissions

Are you currently, or have you ever been a member of any jurisdictions and courts, State and Federal, in which you have been admitted to practice law?

List all jurisdictions and courts, State and Federal, in which you have been admitted to practice law and give dates of admission.

Jurisdiction/Court

Date of Admission

You will need to upload a Certificate of Good Standing from each Jurisdiction/Court.

Name of Jurisdiction/Court

Location of Jurisdiction/Court

Have you been entitled to practice in each of the jurisdictions and courts specified in your answer to this question continuously from the date you first became so entitled until the date hereof?

If NO, list the dates during which you have not been so entitled, the nature of disqualification, the facts and the name and complete mailing address of the authority in possession of the records thereof.

From Mo/Yr

To Mo/Yr

Nature of the disqualification

	The facts

Name of the authority

Address 1

Address 2

City

State

ZIP Code

Province

Country

E-mail

Bar Associations

Are you currently, or have you ever been a member of a bar association?

List the name and complete mailing address of the Director of each bar association of which you are or have ever been a member, and the dates of membership.

Name of Association

Name of Director of Association

Business E-mail

Phone

Address 1

Address 2

City

State

ZIP Code

Country

Province

Dates of membership

From Mo/Yr

To Mo/Yr

Are you currently, or have you ever been a member of an organization whose membership consists primarily of attorneys?

List the name and complete mailing address of each organization whose membership consists primarily of attorneys and of which you are or have ever been a member.

Name of Association

Name of Director of Association

Business E-mail

Phone

Address 1

Address 2

City

State

ZIP Code

Country

Province

Dates of membership

From Mo/Yr

To Mo/Yr

Disbarment

Have you ever been disbarred?

If the answer is YES, please state the date, the nature of the charge, the facts, disposition of the matter, and the name and complete mailing address of the authority in possession of the records thereof and upload a copy of all relevant documentation.

Date

Nature of the charge

	The facts

Disposition of the matter

Name of the authority

Address 1

Address 2

City

State

ZIP Code

Province

Country

E-mail

Suspension

Have you ever been suspended from practice?

Date

Nature of the charge

	The facts

Disposition of the matter

Name of the authority

Address 1

Address 2

City

State

ZIP Code

Province

Country

E-mail

Reprimands

Have you ever been reprimanded, censured, held in contempt of court or otherwise disciplined?

Date

Nature of the charge

	The facts

Disposition of the matter

Name of the authority

Address 1

Address 2

City

State

ZIP Code

Province

Country

E-mail

Charges/Complaints/Pending Charges

Have any charges or complaints, formal or informal, ever been made or filed or proceedings instituted against you? You must disclose all complaints, including pending complaints regardless of the final disposition.

Date

Nature of the charge

	The facts

Disposition of the matter

Name of the authority

Address 1

Address 2

City

State

ZIP Code

Province

Country

E-mail

Grievances

Have you ever appeared, formally or informally, before a grievance or other similar committee of any bar association or other law group?

Date

Nature of the charge

	The facts

Disposition of the matter

Name of the authority

Address 1

Address 2

City

State

ZIP Code

Province

Country

E-mail

Fraud

Have you ever been accused of fraud, commingling, withholding, or misusing funds; or any other charges involving the handling of funds?

Date

Nature of the charge

	The facts

Disposition of the matter

Name of the authority

Address 1

Address 2

City

State

ZIP Code

Province

Country

E-mail

Unauthorized Practice of Law

Have there ever been any charges, complaints, or grievances (formal or informal) alleging that you engaged in the unauthorized practice of law?

Date

Nature of the charge

	The facts

Disposition of the matter

Name of the authority

Address 1

Address 2

City

State

ZIP Code

Province

Country

E-mail

EDUCATION

High School

Name

From Mo/Yr

To Mo/Yr

Address 1

Address 2

City

State

ZIP Code

Country

Province

Colleges and Universities

Name

From Mo/Yr

To Mo/Yr

Degree

Address 1

Address 2

City

State

ZIP Code

Country

Province

Please ensure that the listed Colleges and Universities above, which you have attended, will furnish certified transcripts directly to the Board disclosing your complete educational record. Transcripts must come directly from the educational institutions; those delivered to the Board by the applicant opened are unacceptable.

Law School/Legal Education

List complete information regarding all law school attendance.

Did you (or do you expect to) receive a Juris Doctor from an ABA approved law school?

Law School

Address 1

Address 2

City

State

ZIP Code

Country

Province

From Mo/Yr

To Mo/Yr

Did you receive or do you expect to receive a degree?

Date degree received or expected

Degree received or expected to be received

Was your enrollment primarily online?

Non-ABA Approved Law School/Other

Address 1

Address 2

City

State

ZIP Code

Country

Province

From Mo/Yr

To Mo/Yr

Did you receive or do you expect to receive a degree?

Date degree received or expected

Degree received or expected to be received

Was your enrollment primarily online?

Admission Denial

Have you ever been denied admission to any school, college, law school or other similar institution for cause which might reflect on your character?

If YES, give the name and complete address, including zip code, of any such institution and state the circumstances and date of each occurrence.

Name of Educational Institution

Address 1

Address 2

City

State

ZIP Code

Country

Province

Date

	Explanation

Educational Discipline

Have you ever been dropped, suspended, warned, placed on scholastic or disciplinary probation, expelled or requested to resign from any school, college or university, or otherwise subjected to discipline by any such school or other institution or requested or advised by any such school or institution to discontinue your studies therein?

If YES, give the name and complete address, including zip code, of any such institution and state the circumstances and date of each occurrence.

Name of Educational Institution

Address 1

Address 2

City

State

ZIP Code

Country

Province

Date

	Explanation

Honor Code Violation

Have you ever violated or been formally charged with a violation of the honor code of any educational facility?

If YES, give the name and complete address, including zip code, of any such institution and state the circumstances and date of each occurrence.

Name of Educational Institution

Address 1

Address 2

City

State

ZIP Code

Country

Province

Date

	Explanation

Failure to Disclose

When you applied for admission to law school, did you fail to fully disclose all criminal charges and convictions as requested by the law school application?

If YES, give the name and complete address, including zip code, of any such institution and state the circumstances and date of each occurrence.

Name of Educational Institution

Address 1

Address 2

City

State

ZIP Code

Country

Province

Date

	Explanation

Candor

Have you ever failed to answer fully and truthfully all questions on the application for admission to any educational facility?

If YES, give the name and complete address, including zip code, of any such institution and state the circumstances and date of each occurrence.

Name of Educational Institution

Address 1

Address 2

City

State

ZIP Code

Country

Province

Date

	Explanation

RESIDENCES

Residence History

List below, every permanent and temporary residence you have ever had, including the present, in the United States or elsewhere, since your 21 st birthday, with exact address of each, and the month and year of the beginning and ending of each such residence (Exclude military address, unless off base.).

From Mo/Yr

To Mo/Yr

Address 1

Address 2

City

County

State

ZIP Code

Country

Province

EMPLOYMENT

Employment History

Are you now or have you ever been employed, self-employed or associated with any occasion, business, enterprise, profession or occupation either part-time or full-time OTHER THAN LAW

If so, enumerate all such employments in CHRONOLOGICAL ORDER, since your 21 st birthday. Include employment by members of family or other relatives and employment with or without monetary compensation.

Firm or Employer

Supervisor

Address

City

State

ZIP Code

Country

From Mo/Yr

To Mo/Yr

Phone Number

Position

Nature of Employer's Business

Reason for Termination

With respect to your LEGAL career, list in CHRONOLOGICAL order, from first to current, all employment, including temporary or part-time employment and self-employment, SINCE YOUR FIRST ADMISSION TO PRACTICE in any jurisdiction or court.

If you have had any gap in your employment history, attach an explanation.

If you have not practiced law, please so state.

If the firm or employer is now defunct, include the current address of a reference.

Firm or Employer

Supervisor

Address

City

State

ZIP Code

Country

From Mo/Yr

To Mo/Yr

Phone Number

Position

Nature of Employer's Business

Reason for Termination

Full or Part time?

Public Notice Statement

Public Notice Statement required by N.C. Gen. Stat. § 143-764(a)(5), effective December 31,2017

Any worker who is defined as an employee by N.C. Gen. Stat. §§ 95-25.2(4)(NC Department Of Labor), 143-762(a)(3)(Employee Fair Classification Act), 96-1(b)(10)(Employment Security Act), 97-2(2)(Workers’ Compensation Act), or 105-163.1(4)(Withholding; Estimated Income Tax for Individuals) shall be treated as an employee unless the individual is an independent contractor. Any employee who believes that the employee has been misclassified as an independent contractor by the employee’s employer may report the suspected misclassification to the Employee Classification Section within the North Carolina Industrial Commission.

This Public Notice may also be found at www.ic.nc.gov/121317ECSPublicNotice.pdf

I hereby certify that I have read and understand the Public Notice Statement, referenced above, published by the Employee Classification Section of the North Carolina Industrial Commission.

Employee Misclassification

During the preceding 5 years, have you been the subject of any investigation(s) for employee misclassification?

Please provide a detailed statement regarding the results of said investigation(s) for employee misclassification.

	Explanation

Employment Discharge

Have you been discharged from any employment?

If YES, please state the date, circumstances and name and complete mailing address of employer.

Date of discharge

	Provide an explanation of circumstances of discharge

Name of Employer

Employer E-mail

Address 1

Address 2

City

State

ZIP Code

Resignation in Lieu of Termination

Have you ever been requested, formally or informally, to resign from or terminate employment?

If YES, please state the date, circumstances and name and complete mailing address of employer.

Date of discharge

	Provide an explanation of circumstances of discharge

Name of Employer

Employer E-mail

Address 1

Address 2

City

State

ZIP Code

Judicial Office

Have you ever held judicial office?

If YES, please state where, when, and offices held and if terminated, the reasons for which position was terminated.

Office held

From Mo/Yr

To Mo/Yr

Name of court

Address 1

Address 2

City

State

ZIP Code

Country

Province

Supervisor/Associate name

Supervisor/Associate e-mail

Telephone

Reason for termination (if applicable)

Selective Service

Did you register under the Selective Service Act of 1948?

If NO, please explain.

	Explanation

Military Service

Are you now, or have you ever been a member of the armed forces of the United States?

If YES, list:

Dates of periods of active duty: From Mo/Yr

To Mo/Yr

Branch of service

Date of discharge or expected discharge

As a member of the armed forces, have any charges ever been made or proceedings instituted against you?

If the answer is YES, please state the date, the nature of the charge, the facts, disposition of the matter and the location and designation of the military establishment where such proceeding took place.

Date

Nature of the charge

	The facts

Disposition of the matter

Location and Designation of the military establishment

Have you ever been a defendant in any courts martial?

Date

Nature of the charge

	The facts

Disposition of the matter

Location and Designation of the military establishment

Have you ever received a medical discharge?

If YES, please state the reason.

	Explanation

Have you ever received an administrative discharge?

If YES, please state the reason.

	Explanation

Licenses

Have you held a license or certificate, other than a law license, the procurement of which required proof of good character (i.e. Real Estate License, CPA License, etc.)?

If YES, as to each license or certificate, please state the date it was granted, the name and complete mailing address of the authority issuing it, and whether you are still licensed. If not, state the date your license lapsed, and the reason it lapsed.

Type of license

License number

Issued date

Name of authority

Address 1

Address 2

City

State

ZIP Code

Country

Province

License Denial

Have you ever made application for a position, the procurement of which required proof of good character, which application was denied?

If YES, then as to each such application, state the name and complete mailing address of the authority to whom it was addressed, date application was made, and the reasons for denial.

Name of authority

Address 1

Address 2

City

State

ZIP Code

Country

Province

Date

	Reasons of denial

License Revocation

Have you ever held a license or certificate, the procurement of which required proof of good character, which license or certificate was revoked or suspended?

If YES, as to each such license or certificate, please state the date it was revoked or suspended, and the name and complete mailing address of the issuing and revoking authority, and the reason for the revocation or suspension.

PLEASE UPLOAD a copy of the Order of Revocation or Suspension foreach action listed.

Date of revocation/suspension

Name of authority

Address 1

Address 2

City

State

ZIP Code

Country

Province

	Reason of revocation/suspension

CHARACTER & FITNESS

Surety Bond

Have you ever been bonded under a surety bond?

Name of Surety (Bonding) Company

Address 1

Address 2

City

State

ZIP Code

Country

Phone

E-mail

Amount of Money paid by Surety

Date of money paid

Reason for Bond

	Explanation

If you have ever been bonded under a surety bond, has anyone ever sought to recover upon such bond or to cancel the same?

If YES, please specify nature of office or position for which you were bonded, dates, amount of bond, and name of surety company.

	Explanation

Have you ever been refused a fidelity or other bond?

If YES, give full details below.

	Explanation

Debt Judgments

Have any judgments ever been entered against you?

If YES, PLEASE UPLOAD a copy of such judgments, satisfactions and, if unsatisfied, the names and present complete mailing addresses of the holders.

Court filed

Date Filed

Address 1

Address 2

City

State

ZIP Code

Province

Country

Judgment holder

Address 1

Address 2

City

State

ZIP Code

Province

Country

Amount owed

Status

	Explanation

Debt Default or Discharge

Are you in default in the performance or discharge of any duty or obligation imposed upon you by any governmental agency or decree or order of any court including alimony and support orders and decrees? Please do not list Student Loan debt in this section.

Agency/Court

Address 1

Address 2

City

State

ZIP Code

Province

Country

Amount owed

Status

	Explanation

Taxes

Have you failed to file any personal local, state, or federal income tax return, or failed to pay any taxes due?

If YES, give full details below and upload documentation showing taxes are current.

Agency

Address 1

Address 2

City

State

ZIP Code

Province

Country

Amount owed

Status

	Explanation

Bankruptcy

Have you been involved as a debtor in proceedings filed under provision of the Bankruptcy Act?

If YES, give full details below.

PLEASE UPLOAD A COPY OF ALL BANKRUPTCY DOCUMENTATION

Date filed

Title of action

Type of bankruptcy

Court file number

Name of court involved

Address 1

Address 2

City

State

ZIP Code

Country

Province

Total amount discharged in U.S. dollars

Date of disposition

Disposition

Were any adversary proceedings instituted?

Were there any allegations of fraud?

Were any debts not discharged?

	Detailed description of circumstances surrounding filing

Student Loans

Do you have students loans?

List all student loans and indicate whether payments are current, deferred or delinquent. Upload documentation from the lender(s) for any current payback schedules, deferred payments or defaults.

Name of creditor

Address 1

Address 2

City

State

ZIP Code

Country

Province

Full account number

Date repayment begins

Balance

Status

Have you ever defaulted on the payment of any student loan? If so provide documentation from the lender(s) showing resolution of any default.

If YES, give full details below.

	Explanation

Debts Over $1000

Do you have any outstanding debts over $1000?

List all debts over $1000 and indicate status, i.e. current or delinquent. Include any active credit cards you have, regardless of whether or not you have a balance due on said credit card.

BE SURE TO GIVE COMPLETE MAILING ADDRESS and ACCOUNT NUMBER.

Type of debt

Full account number

Original amount of debt

Current balance

Date of last payment

Current status of this debt

	Describe the history of this debt

Name of entity extending credit

Address 1

Address 2

City

State

ZIP Code

Country

Province

Telephone number

Name of retailer if different from above

Name of current creditor or collection agency if different from above

Address 1

Address 2

City

State

ZIP Code

Country

Province

Telephone number

Debt Revocation

Have you ever had a credit card revoked or canceled?

If YES, explain fully the circumstances leading to such a revocation, substantiating any repayment arrangements, including verification of current pay status or satisfaction.

	Explanation

Debts

Have you ever had a credit account involuntarily closed, charged-off, or referred to a collection agency?

Type of debt

Full account number

Original amount of debt

Current balance

Date of last payment

Current status of this debt

	Describe the history of this debt

Name of entity extending credit

Address 1

Address 2

City

State

ZIP Code

Country

Province

Name of retailer if different from above

Name of current creditor or collection agency if different from above

Address 1

Address 2

City

State

ZIP Code

Country

Province

Telephone number

Current full account number

Non-Legal Claims

Has anyone asserted a claim or demand against you, which has not been made the subject of any action or legal proceeding?

If YES, state the facts and the present status of the matter.

	Explanation

Have you ever asserted any claim or demand against any person, partnership or corporation, or governmental agency, which has not been made the subject of any action or legal proceeding?

If YES, state the facts and the present status of the matter.

	Explanation

Administrative Actions

Have you ever had a complaint filed against you personally, or as a member of a professional association, or corporation, or any legal entity in any civil, criminal or administrative forum alleging fraud, deceit, misrepresentation, forgery or professional malpractice.

If YES, list details below.

Name of regulatory agency

Address 1

Address 2

City

State

ZIP Code

Country

Province

Case number

Action taken

Action date

	Explanation

Legal Actions

Have you ever been a named party to any legal action, including, but not limited to civil, equitable, family law, probate, guardianship, or special proceedings? CRIMINAL MATTERS should be listed in response to the Criminal Actions questions in this application. PLEASE UPLOAD A COPY OF ALL LITIGATION.

If YES, list details below.

Complaint/Pleading, Answer, Judgment/Final order/Disposition, etc. and complete the following:

Please include a brief summary of the circumstances surrounding each action.

Date

Nature of Proceedings

Plaintiffs

Defendants

Disposition

	Explanation

Driver’s License Cancellation/Suspension/Revocation

Has your driver's license been canceled, suspended or revoked for any reason?

If YES, give full details below.

	Explanation

Criminal Actions - Violations

Have you EVER IN YOUR ENTIRE LIFE been arrested, given a written warning, or taken into custody, or accused, formally or informally, of the violation of a law for an offense other than traffic violations?

Date

Place

Charges At Arrest

Final Disposition

Amount Fined

	Explanation

Criminal Actions - DWI/DUI

Have you been charged with or convicted of DWI/DUI; or driving under the influence of drugs?

Providing attachments of letters from law enforcement agencies in lieu of an answer is not acceptable.

Note: For each incident, upload a copy of the arresting officer’s report, complaint, indictment, trial disposition, sentence appeal, and criminal record check. (If this information is not available, upload a letter from the court stating that there is no record.)

Date (or time period) of incident

Charge(s) on date of arrest or citation

Incident location

City

County

State

Country

Province

Title of complaint, indictment, or citation

Court file number

	Detailed description of violation

Name of court involved

Address 1

Address 2

City

State

ZIP Code

Country

Province

Name of law enforcement agency involved

Address 1

Address 2

City

State

ZIP Code

Country

Province

Name of defendant’s attorney

Date of initial court hearing

Charge(s) at time of initial court hearing

Date of final disposition

Charge(s) at time of final disposition

Final disposition

Criminal Actions - Vehicular Violations

Have you ever been charged with a traffic violation which resulted in time spent in jail, or had a jail sentence suspended, or charged with vehicular manslaughter, or charged with vehicular homicide?

If YES, complete the following

Date

Place

Charges At Arrest

Final Disposition

Amount Fined

	Explanation

Traffic Violations

During the past five years have you been arrested, given a written warning, or taken into custody, or accused, formally or informally of the violation of a traffic law or ordinance, other than parking offenses? (This includes safety violations)

If YES, complete the following:

Date

Place

Police Agency

Address 1

Address 2

City

State

ZIP Code

Province

Country

Court

Address 1

Address 2

City

State

ZIP Code

Province

Country

Charges At Arrest

Final Disposition

Amount Fined

	Explanation

Failure to Appear

Have you ever failed to appear in regard to any court proceeding?

If YES, list each incident, provide an explanation of the circumstances surrounding the incident, including date(s) and the name and address of the court involved.

	Explanation

Fingerprinting

The following are the approximate dates of each time I have been fingerprinted and the reason why I was fingerprinted.

Have you ever been fingerprinted?

Mo/Yr

Agency

Address 1

Address 2

City

State

ZIP Code

Province

Country

	Explanation

Immunity

Have you ever been offered or granted immunity, testified or been called as a witness in a criminal action or criminal proceeding in which you were not a party?

If YES, state the place, date, name of the defendant, nature of the action or the proceeding, the court and the complete circumstances.

Place

Date

	Name of each defendant

	Nature of the action or the proceeding

Name of court

Address 1

Address 2

City

State

ZIP Code

Province

Country

	Circumstances

Business Litigation

Have you ever been a party to any litigation or other proceeding (including every cease and desist order, or other order) in any court of law or equity or any criminal court or before any governmental board or agency, or any arbitration board, in which any corporation, business association, business trusts, limited partnership, nonprofit corporation or association, and charitable religious or government funding agency in which you have ever owned 10% or more of the capital stock or other property interests, either legally or equitably, has been a party (a) during the period of time in which you owned 10% or more of the capital stock or other property interest in any said entity, or (b) during the period of time in which you were an officer, director, or trustee of any said entity.

Name of Court or Agency

Number of Case

Name of Plaintiff or Prosecutor

Name of Defendant

Type of Proceeding

Disposition

Date of Disposition

	Explanation

The following is a complete list of all judgments, liens, orders and decrees ever entered against any entity listed above, remaining unsatisfied as of the present date.

	Explanation

Preamble to Impairment Questions

Through this application, the Board of Law Examiners makes inquiry about circumstances that may affect an applicant’s ability to meet the professional responsibilities of a lawyer. This information is treated confidentially by the Board. The purpose of such inquires is to allow the Board to determine the current fitness of an applicant to practice law. The mere fact of treatment, monitoring, or participation in a support group is not, in itself, a basis on which admission is denied; the Board routinely admits individuals who demonstrate personal responsibility and maturity in dealing with fitness issues. The Board encourages applicants who may benefit from assistance to seek it.

The Board does, on occasion, deny admission to applicants whose ability to function is impaired in a manner relevant to the practice of law at the time that the licensing decision is made, or to applicants who demonstrate a lack of candor by their responses. This is consistent with the public purpose that underlies the licensing responsibilities assigned to the Board; further, the applicant has the responsibility for demonstrating qualification to practice law.

The Board does not seek information that is fairly characterized as situational counseling. Examples of situational counseling include stress counseling, domestic counseling, grief counseling, and counseling for eating or sleeping disorders.

I certify that I have read and understand the information in the preamble.

Conduct or Behavior

Within the past five years, have you exhibited any conduct or behavior that could call into question your ability to practice law in a competent, ethical, and professional manner?

If you answered yes, furnish a thorough explanation below:

	Explanation

Date

Condition or Impairment

Do you currently have any condition or impairment (including, but not limited to, substance abuse, alcohol abuse, or a mental, emotional, or nervous disorder or condition) that in any way affects your ability to practice law in a competent, ethical, and professional manner?

Note: In this context, "currently" means recently enough that the condition or impairment could reasonably affect your ability to function as a lawyer.

If Yes, complete and upload a Form 7 and Form 8 for each service provider.

Are the limitations caused by your condition or impairment reduced or ameliorated because you receive ongoing treatment or because you participate in a monitoring or support program?

From Mo/Yr

To Mo/Yr

	Description of condition or impairment

	Description of treatment or monitoring/support program

Name of attending physician or counselor (if not applicable please type N/A)

Address 1

Address 2

City

State

ZIP Code

Country

Province

Telephone

E-mail

Name of hospital or institution (if not applicable please type N/A)

Address 1

Address 2

City

State

ZIP Code

Country

Province

Telephone

Defense or Explanation

Within the past five years, have you engaged in any conduct that: (1) resulted in arrest, discipline, sanction or warning; (2) resulted in termination or suspension from school or employment; (3) resulted in loss or suspension of any license; (4) 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; or (5) endangered the safety of others, breached fiduciary obligations, or constituted a violation of workplace or academic conduct rules? If so, provide a complete explanation and include all defenses or claims that you offered in mitigation or as an explanation for your conduct.

If you answered yes, furnish the following information:

Name of entity before which the issue was raised (i.e., court, agency, etc.)

Address 1

Address 2

City

State

ZIP Code

Country

Province

Nature of the proceeding

Date

Disposition, if any

	Explanation

Anti-Government Associations

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 subdivisions thereof should be overthrown or overturned by force violence or any unlawful means?

If your answer is YES, give full details below.

	Explanation

If YES, did you, during the period of such membership or association, have the specific intent to further the aims of such organization or group of persons to overthrow or overturn the government of the United States or any state or any political subdivision thereof by force, violence, or any unlawful means?

CHARACTER REFERENCES

Certificates of Moral Character

The following four (4) persons, none of whom is a relative, a current or former supervisor, ARE NOT listed under General Character References, and have known me well for a number of years and will furnish a Certificate of Moral Character to the Board of Law Examiners.

Name - Please indicate correct title (Mr./Ms.)

Address 1

Address 2

City

State

ZIP Code

Country

General Character References

The following eight (8) persons, none of whom is a relative, a current or former supervisor, and IS NOT listed under Certificates of Moral Character, have known me well for a number of years and they can be found at the indicated mailing addresses:

(Please make certain that no two persons are members of the same household.) SET OUT COMPLETE and CURRENT MAILING ADDRESS for each person listed. If it is a business address, please include the name of the business.

Name - Please indicate correct title (Mr./Ms.)

Business Name

Address 1

Address 2

City

State

ZIP Code

Country

Length of Time Known

Attorney/Client References

Please give names and complete mailing addresses of three (3) attorneys and two (2) clients who know you, who are not relatives and are not listed elsewhere in this application. Do not list current or former supervisors as references. If it is a business address, please include the name of the business.

YOU MUST LIST FIVE (5) REFERENCES

Name - Please indicate correct title (Mr./Ms.)

Business Name

Address 1

Address 2

City

State

ZIP Code

Country

Length of Time Known

Practice of Law References

Please state the names, complete mailing addresses and occupations of five (5) reputable and responsible persons from the jurisdiction(s) in which you are relying upon admission in North Carolina by comity with whom you are personally acquainted and who are not previously listed elsewhere in this application. Do not list current or former supervisors as references. If it is a business address, please include the name of the business.

Name - Please indicate correct title (Mr./Ms.)

Business Name

Address 1

Address 2

City

State

ZIP Code

Country

Occupation

ADDITIONAL INFORMATION

Marital Status

Your current marital status

Provide the date of marriage and full name of partner

Date of marriage

Full name of spouse or partner

If married and living apart, has separation been the subject of legal proceedings?

PLEASE UPLOAD a copy of separation documents.

Prior Marriage

Except as previously-stated, have you ever been married?

Please state when, where and with whom such marriage was contracted, and when and how the marital status was terminated. Please upload a copy of the complaint or other initial pleading; answer; counterclaim; agreement, if any; final judgment or other disposition; any post-judgment proceedings; and list the names and addresses of all attorneys who participated, the names of the parties to such proceedings and the names and addresses of the courts in which the proceedings were instituted or maintained.

	Explanation

Support/Alimony

Have you ever been required to pay support or alimony payments?

If YES, please advise the Board of the status of your compliance with the support or alimony Order and list the name and last known complete address, including zip code, of the person receiving support or alimony payments.

First Name

Last Name

Address 1

Address 2

City

State

ZIP Code

Country

Province

Full Disclosure

FULL DISCLOSURE: Is there any other incident or occurrence in your life which is not otherwise referred to in this application which you would like to acknowledge in the interest of full disclosure. It is crucial that you honestly and fully answer all questions, regardless of whether you believe the information is relevant.

	Explanation

MPRE

Have you passed the Multistate Professional Responsibility Examination (MPRE)? [Pursuant to Rule .0502(8), you must have taken and passed the MPRE.]

Date you passed the MPRE

What date were your MPRE scores requested?

Date you plan to take the MPRE