DATED: _____________________
NAME OF
APPLICANT:__________________________________________________________________

FIRM NAME:__________________________________________________________________

ADDRESS:____________________________________________________________________
_____________________________________________________________________________
CITY:_____________________________________STATE:________ZIP CODE:___________

TELEPHONE: (_____)_______________________FAX: (_____)________________________

E-MAIL:__________________________________S.S.#:_______________________________
NY BAR ADMISSION DATE:________________DEPARTMENT_______________________

I HAVE AN OFFICE AND/OR RESIDENCE IN PANEL COUNTY (Y/N):________________

I HAVE ATTENDED FUNDAMENTALS OF LAW GUARDIAN ADVOCACY (Y/N):______

I HAVE PARTICIPATED AS COUNSEL OF RECORD OR AS CO-COUNSEL WITH A LAW
GUARDIAN MENTOR IN:

(1) A JUVENILE DELINQUENCY OR PERSON IN NEED OF SUPERVISION
PROCEEDING ENTITLED
_________________________________________________________________

IN ___________________ COUNTY FAMILY COURT;

(2) A CHILD ABUSE, CHILD NEGLECT, OR TERMINATION OF PARENTAL
RIGHTS PROCEEDING ENTITLED

________________________________________________________________

IN ____________________________ COUNTY FAMILY COURT;

(3) A CUSTODY OR VISITATION PROCEEDING ENTITLED
__________________________________________________________________

IN ____________________________ COUNTY FAMILY COURT;
AND HAVE PARTICIPATED IN OR OBSERVED TWO HEARINGS IN FAMILY
COURT AT WHICH TESTIMONY WA TAKEN ENTITLED
____________________________________________________________
IN___________________COUNTY FAMILY COURT; AND
____________________________________________________________
IN___________________COUNTY FAMILY COURT.

I WAS PREVIOUSLY A MEMBER OF THE LAW GUARDIAN PANEL FOR _____________
COUNTY FROM ___________________ UNTIL ______________________.

I HAVE THE FOLLOWING ADDITIONAL TRAINING AND EXPERIENCE RELATED TO
SERVICE AS A LAW GUARDIAN:
_______________________________________________________________________________

I CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE
AND CORRECT.

DATED:_______________________ APPLICANT SIGNATURE:_______________________