VIRGINIA BOARD OF BAR EXAMINERS

APPLICANT'S CHARACTER AND FITNESS QUESTIONNAIRE In the Matter of the Application of

(Full Name - No Initials)

EXPLANATION AND INSTRUCTIONS Before being issued a license to practice law in Virginia, each applicant is required by statute to produce to the Virginia Board of Bar Examiners evidence sufficient to satisfy the Board that the applicant is a person of honest demeanor and good moral character and possesses the requisite fitness to perform the obligations and responsibilities of a practicing attorney at law. Va. Code Ann. 54.1-3925.1. The standards for making such evaluation are set forth in the Board's Rules. Completion of this Applicant's Character and Fitness Questionnaire is the first step in this process. You must answer each question on this questionnaire fully and truthfully. Any omission, untruthful answer, or incomplete answer may result in your being denied the privilege of taking the Virginia Bar Examination and practicing law in Virginia. If you have any doubts about whether any matter should be reported on this questionnaire, report it. If you are not sure of dates, time, places, or other information requested, it is your responsibility to consult the court, governmental agency, or other entity or person involved to obtain the accurate and complete information. If the space provided for any answer is inadequate, complete your answer on a separate sheet, specifying the question to which it relates. Affix your signature to each additional sheet you submit with the questionnaire. Your answers to the questionnaire must be verified before a Notary Public. Two (2) completed TYPEWRITTEN copies of this questionnaire (the original and one photocopy), both bearing your original signature under oath or affirmation, must be submitted to the Secretary of the Virginia Board of Bar Examiners along with the appropriate fee, in accordance with the fee schedule currently in effect. Applicants are encouraged to submit their completed questionnaire as soon as possible after they begin their second semester of law school. No Application for Examination will be accepted unless the applicant's completed Character and Fitness Questionnaire, with the applicable fee, has been previously filed with the Secretary of the Board or is filed simultaneously with the Application for Examination. Within three months prior to the bar examination you will be required to file a supplemental questionnaire as a part of your Application for Examination. Keep a photocopy of your completed Character and Fitness Questionnaire with your personal records. Your completed questionnaire, fee, and all required attachments should be filed with: Secretary Virginia Board of Bar Examiners 2201 W. Broad Street Suite 101 Richmond, Virginia, 23220

I understand that this questionnaire is NOT the application to take the Virginia Bar Examination and that I must file a separate Application for Examination, on the form prescribed by the Board of Bar Examiners, by the statutory filing deadline IN ADDITION TO this Character and Fitness Questionnaire.

1.

(a) (b)

Your full legal name (First, Middle, Last) Have you ever used or been known by any other name (other than a nickname), including but not limited to a maiden name or former married name? yes no If so, state in full each name used or by which you have been known, the dates during which the name was used, and the reasons for using the name.

(c)

Has your name ever been changed legally?

yes

no

If so, attach a certified copy of the name change order. (d) What is your social security number?
Your social security number may be used by the Board of Bar Examiners and the National Conference of Bar Examiners to obtain background information on you from law enforcement, credit, and other agencies or entities. Disclosure of your social security number (or Virginia Dept. of Motor Vehicles control number) is required by 54.1-116 of the Code of Virginia and assists in expediting the character review process.

(e)

List all states in which you are currently licensed to operate a motor vehicle and your operator's license number for each state.

List all states in which you have previously held a license to operate a motor vehicle.

For every state in which you currently hold, or have previously held, a license to operate a motor vehicle, attach a current (issued within the past 6 months) transcript of your driving record (i.e., a DMV report). 2. (a) (b) (c) Date of birth Place of birth If you were born in a foreign country, at what age did you come to the USA? yrs.

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(d)

If you claim citizenship other than by birth in the United States, give: Date of Certificate Court

(d)

If you are not a citizen of the United States, describe your immigration status and provide your alien registration number here: If you do not have a Resident Alien number, please explain.

3.

(a) Legal residence (permanent) address

(Street)! (City, State, Zip)

Beginning with your current address, list all addresses (permanent and temporary) where you have lived since your 18th birthday or for the past 10 years, whichever is shorter, giving the exact address of each, together with the month and year of the beginning and ending of each residence. For each address listed, indicate with whom you lived. For your current address, indicate your telephone number. The Board of Bar Examiners should mail correspondence and other information to my permanent address. current

(Mo./Yr.) Current address from ____ / _____ to present (Street, Apt.)! (City, County)! (State, Zip)

Telephone Number (_____)

(Mo./Yr.) Prior address from ____ / __ (Street, Apt.)! (City, County)! (State, Zip)

(Mo./Yr.) to _____ / ______

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(Mo./Yr.) Prior address from ____ / _____ (Street, Apt.)! (City, County)! (State, Zip)

(Mo./Yr.) to _____ / ______

(Mo./Yr.) Prior address from ____ / _____ (Street, Apt.)! (City, County)! (State, Zip)

(Mo./Yr.) to _____ / ______

(Mo./Yr.) Prior address from ____ / _ ____ (Street, Apt.)! (City, County)! (State, Zip)

(Mo./Yr.) to _____ / ______

(Mo./Yr.) Prior address from ____ / _____ (Street, Apt.)! (City, County)! (State, Zip)

(Mo./Yr.) to _____ / ______

ANY CHANGE OF PERMANENT OR CURRENT RESIDENCE ADDRESS SHOULD BE REPORTED IMMEDIATELY TO THE SECRETARY OF THE BOARD OF BAR EXAMINERS. THIS IS IMPORTANT FOR MAILING REQUESTS FOR ADDITIONAL INFORMATION, NOTICES FOR POSSIBLE INTERVIEW, RESULTS OF YOUR CHARACTER REVIEW, AND OTHER ADMISSION INFORMATION. Copy this sheet as necessary

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4.

(a)

Indicate your marital status. Single Married Separated but not divorced Divorced Widowed

(b)

If you are married, state the date of your marriage and your spouse's full name (include a maiden name, if applicable).

(c)

If you have had a marriage terminated by divorce, annulment, dissolution, or any other legal termination or separation, give the title and number of the case, the name and address of the court granting the decree, date of the decree, grounds for termination, and name and address of your legal counsel.

(d)

List all post-judgment actions filed in any of the matters listed in 4(c) above, including but not limited to motions, citations in contempt, child custody actions, or motions filed in this state or any other state, and any actions brought for child support, whether by a local child support enforcement agency, an agency from another state, or otherwise. For each of these actions, give the title and the number of the case, the name and address of the court involved, the disposition or status of the matter, and the name and address of your legal counsel.

5.

(a)

List all high schools you have attended, beginning with most recent. Give the name and location of the high school and the period of attendance (from and to dates).

(Name and location)! (From [date] to [date])

(b)

List all colleges, universities, trade schools, or other post-high school educational facilities (except law school) you have attended, beginning with most recent. Give the name and complete address of the facility (including zip code), the period of attendance (from and to dates), and degree and date received.

(Name and complete address, including zip code)! (From [date] to [date])! (Degree and date received)

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(c)

List all law schools you have attended, beginning with most recent. [If you studied law in the office of an approved Virginia attorney pursuant to 54.1-3926.2 of the Code of Virginia, list the name and address of your supervising attorney(s) and the dates of your study.] Give the name and complete address of the law school (including zip code), the period of attendance (from and to dates), and degree and date received.

(Name and complete address, including zip code)! (From [date] to [date])! (Degree and date received)

(d) 6. (a)

Indicate the date you expect to or did graduate from law school.

(Date)
Have you ever been disciplined, placed on probation, suspended, expelled or requested to terminate your enrollment, or allowed to resign in lieu of discipline at any high school, college, university, law school, trade school or any other post-high school educational facility? yes no Have you ever been charged with violating the honor code of any educational facility (regardless of the disposition of the charge)? yes no If your answer to (a) or (b) is "yes," give the name and address of the institution, a description of the violation and any action by the institution, the date of the action and a full explanation of the reasons for such action. Use a separate page, if necessary.

(b) (c)

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7.

(a)

Are you now or have you ever been a member of the Armed Forces of the United States, its Reserve components, or the National Guard? I have never been a member of the Armed Forces. (Answer section B.) I was formerly a member of the Armed Forces. (Answer sections B, C, E, and F.) I am presently a member of the Armed Forces. (Answer sections B, C, D, and F.)

(b)

Have you ever been rejected for service in any branch of the Armed Forces of the United States? yes no If so, state the reason for the rejection, the date, and any other pertinent facts.

(c)

Give your type and branch of service: Regular Armed Forces Air Force Army Coast Guard Marine Corps Navy Rank Dates of Service: From Mo/Yr to Mo/Yr From Mo/Yr to Mo/Yr Reserve Component Air Force Army Coast Guard Marine Corps Navy National Guard Air Force Army

(d)

If you are currently a member of the Armed Forces, provide the following information. Active Reserve

Present duty station Address Telephone Number ( )

Commanding Officer's Name and Phone Number

(e)

If you were formerly a member of the Armed Services, provide the following information and attach a copy of REPORT OF SEPARATION DD FORM 214 to your completed questionnaire. I received an Honorable Discharge. I did not receive an Honorable Discharge. (Answer the following questions.) Type of discharge Circumstances surrounding your discharge:

(f)

If you have ever served in the Armed Forces of the United States, were you ever a defendant in any courts-martial? yes no If so, give the date, the nature of the charge, the facts pertaining to the case, and the disposition thereof.

8.

(a)

Your current employment.

Name of Employer or Business Address

(Street)! (City, State, Zip)

Telephone Number ( Position

(b) Answer the following for to ALL your past employment for the ten year period prior to the date of this questionnaire, or since age 18, whichever is shorter. If an employer's address is currently other than where you worked, list BOTH the address where you were employed AND the employer's current address. If you are or were self-employed, or if a former employer is no longer in business, list the name, current address, and telephone number of a verifying reference. Name of Employer or Business Complete Address (Street)! (City, State, Zip) Period of Employment: From Reason for Leaving to Position

Name of Employer or Business Complete Address (Street)! (City, State, Zip) Period of Employment: From Reason for Leaving to Position

Name of Employer or Business Complete Address (Street)! (City, State, Zip) Period of Employment: From Reason for Leaving to Position

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Name of Employer or Business Complete Address (Street)! (City, State, Zip) Period of Employment: From Reason for Leaving to Position

Name of Employer or Business Complete Address (Street)! Period of Employment: From Reason for Leaving

(City, State, Zip)

Name of Employer or Business Complete Address (Street)! (City, State, Zip) Period of Employment: From Reason for Leaving to Position

(c)

Have you ever been discharged or asked to resign by any employer?

yes

no

If your answer to this question is "yes," identify the employer and give the full particulars as to the reason you were discharged or asked to resign.

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9.

To your knowledge, have you ever been denied a security clearance, or has a security clearance previously granted to you ever been revoked? yes no If your answer is "yes," explain fully, including the name of the issuing agency, the security designation, and the particulars of the revocation or denial of the clearance.

10.

Have you ever held, or submitted an application, or in any way applied for a license or certificate, including but not limited to any license or certificate to practice law in any jurisdiction, the procurement of which requires proof of good character (including any bar exam applications or other applications for admission, even if you failed a bar exam or withdrew your application for any reason)? yes no If so, as to each license or certificate, identify the type of license or certificate and state the date it was granted, the name and complete current mailing address of the authority issuing it, whether the license or certificate has been refused or revoked, and whether you have been reprimanded, censured, or otherwise disciplined as the holder of the license or certificate. You MUST include in your response applications or other submissions to any jurisdiction to register as a law student, to seek character certification, to take that jurisdiction's bar examination, to become eligible to participate in clinical education or third year practice programs, or to be admitted to practice in that jurisdiction without examination. Do NOT send a copy of your application(s).

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THE FOLLOWING QUESTIONS MUST BE ANSWERED FULLY, REGARDLESS OF BOND FORFEITURES, DISMISSALS, OR SIMILAR TERMINATIONS. You must also complete Part 1 of the attached CRIMINAL HISTORY RECORD REQUEST form and submit it with this questionnaire. 11. (a) State whether you have ever been, or presently are, a party to or otherwise involved (except as a witness) in: (1) (2) (3) (b) (c) any civil or administrative action or legal proceeding; yes no

any criminal or quasi-criminal action or legal proceeding (whether involving a felony, misdemeanor, minor misdemeanor, or any traffic offense); yes no Any action or legal proceeding in a juvenile court. yes no

Have you ever been summoned for a violation of any other statute, regulation or ordinance? yes no Do you have any outstanding or unpaid fines, court costs, or tickets, including those for traffic or parking violations? yes no Have you ever been removed, resigned, or asked to resign as a guardian, executor, administrator, trustee, or other fiduciary? yes no Have you ever been granted immunity from prosecution? yes no Have you ever been cited or arrested for contempt of court for any reason, including, but not limited to, failure to appear as a witness or answer a subpoena or jury summons? yes no Has your driver's license ever been revoked or suspended within the last ten (10) years? yes no

(d)

(e) (f)

(g)

If your answer to any section above is "yes," attach a separate sheet of paper, identified in accordance with the instructions on the first page hereof, on which you set forth the facts in detail, designating by letter the portion of the question to which you refer. If any court or agency proceedings were involved, state the names, case numbers, and dates of all court or agency proceedings, including an accurate description of the ORIGINAL CHARGE, regardless of a finding of guilt of a lesser offense or a complete dismissal; the dispositions made thereof; the names and addresses of the courts or agencies in which the record may be found; and the name and address of your legal counsel in each proceeding. Non-disclosure of a criminal charge is allowable only when the charge has been expunged in accordance with applicable state law.

12.

(a)

Have you ever filed or been the subject of a petition in bankruptcy? yes no

If your answer to 12(a) is yes, attach a copy of your bankruptcy petition, including a copy of all schedules and all orders entered in the case. (b) Have you ever been the subject of a trusteeship, receivership, wage attachment or garnishment proceeding? yes no Have you ever been engaged in business or been a director, an officer, a more than five percent shareholder, a partner or a joint venturer in any business enterprise? yes no If so, answer the following: (1) List each business or enterprise.

(c)

(2)

Have any of the businesses or enterprises ever been insolvent or filed for protection from its creditors? yes no Have any of the businesses or enterprises ever been involved in litigation? yes no

(3)

(In the event you are interviewed by a representative of the Board, you may be asked to discuss the details involving your participation in the business or enterprise, any litigation in which it has been involved, or any unsatisfied judgments against it. Please be prepared to answer these inquiries.)

(d) (e)

Have you ever had a credit card revoked? yes no Have you any debts with an outstanding balance of $300.00 or more, including student loans, that are more than 90 days past due? yes no Have you any unsatisfied judgments against you? yes no

(f)

If your answer to any of the above sections of Question 12 is "yes," set forth the facts in detail, on a separate page, designating by letter the portion of the question to which you refer.

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(g)

For any credit card revocations or loan defaults, list the creditor's NAME, CURRENT ADDRESS, and your ACCOUNT NUMBER. If any court or agency proceedings were involved, state the names, case numbers, and dates of all court or agency proceedings; the dispositions made thereof; the names and addresses of the courts or agencies in which the records may be found; and the name and address of your legal counsel in each proceeding.

(h)

All Applicants: ATTACH TO THIS QUESTIONNAIRE A CURRENT (dated within sixty days of the date you file this questionnaire) CREDIT REPORT ON YOURSELF, FROM A NATIONALLY RECOGNIZED CREDIT REPORTING AGENCY. (E.g., Equifax, Experian (formerly TRW), or Trans Union. The toll free number for Equifax is 1-800-685-1111.)

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13.

(a) Have you ever applied for or obtained a STUDENT LOAN?

yes

no

If so, list every student loan you have obtained, whether guaranteed or not and from whatever source and whether paid in full, not yet in repayment, or in repayment. Creditor's Name & Current Address Account Number Original Loan Amount Date of Disbursement Amount Owed Date Payments to Begin

(b) Have you ever defaulted on any student loan? (Answer yes even if the debt is now satisfied) yes no If so, give the name and current address of the creditor, the loan account number, the amount owed, and, if still in default, what steps have been taken to bring the account current.

ATTACH CURRENT DOCUMENTATION FROM YOUR LENDER OR SERVICER SHOWING THE STATUS OF EACH DEFAULTED STUDENT LOAN (c) Has a judgment ever been entered against you in favor of a student loan guarantor or lender? yes no If so, list the names and current addresses of the holders, furnish certified copies of such judgments and, if satisfied, satisfactions of judgments.

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14.

List below five character references resident in the United States, none of whom may be a relative or an in-law. 3 of the character references must have known you well for at least 5 years. The remaining 2 character references must have known you well at some time during the last 2 years. Name Address Residence Business Occupation Name Address Residence Business Occupation Name Address Residence Business Occupation Name Address Residence Business Occupation Name Address Residence Business Occupation How long known? How long known? How long known? How long known? How long known?

(Street)! (City, State, Zip)

(Street)! (City, State, Zip)

(Street)! (City, State, Zip)

(Street)! (City, State, Zip)

(Street)! (City, State, Zip)

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15.

(a) (b)

To your knowledge, has your conduct ever been questioned with reference to the unauthorized practice of law? yes no To your knowledge, have you ever been employed or otherwise connected with any person, firm or corporation whose conduct was questioned on the subject of unauthorized practice of law while you were so employed or connected? yes no If your answer to either section above is "Yes," explain the facts in detail.

16.

If you have ever held any public office either by election or by appointment, state the position you held, the nature of your duties, when you held the position, and where you held it.

17.

(a) (b)

Have you ever been suspended, censured, reprimanded, disqualified or otherwise disciplined as a member of any profession? yes no Have you ever been removed from any office, public or private, because of conduct reflecting upon your character, or have any charges been made or filed or proceedings instituted against you because of conduct reflecting on your character? yes no Have there ever been or are there now pending any charges, complaints, or grievances (formal or informal) concerning your conduct as a member of any profession or as a holder of public office? yes no

(c)

If your answer to any section above is "yes," explain the facts in detail, including in your explanation the name and complete address of the authority in possession of the results regarding the action.

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The following inquiries address recent mental health and chemical or psychological dependency matters. The purpose of such inquiries is to determine the current fitness of an applicant to practice law. The mere fact of treatment for mental health problems or chemical or psychological dependency is not, in itself, a basis on which an applicant is ordinarily denied admission in Virginia, and the Board of Bar Examiners regularly licenses individuals who have demonstrated personal responsibility and maturity in dealing with mental health and chemical or psychological dependency issues. The Board encourages applicants who may benefit from treatment to seek it. On occasion a license is denied or deferred when an applicant's ability to function is impaired in a manner relevant to the practice of law at the time that the licensing decision is made, or when an applicant demonstrates a lack of candor by his or her responses. This is consistent with the public purpose that underlies the licensing responsibilities assigned to the Board of Bar Examiners; further, each applicant is responsible for demonstrating that he or she possesses all the qualifications to practice law. The Board does not, by its questions, 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. Generally, the Board does not view these types of counseling as germane to the issue of whether an applicant is qualified to practice law. ______________________________ 18. (a) Have you been chemically or psychologically dependent upon or treated for the use of any drug, including alcohol? yes no Within the past five years, have you been diagnosed with or have you been treated for any of the following: schizophrenia or any other psychotic disorder, delusional disorder, bipolar or manic depressive mood disorder, major depression, anitsocial personality disorder, or any other condition which significantly impaired your behavior, judgment, understanding, capacity to recognize reality, or ability to function in school, work, or other important life activities? (If you are uncertain of a diagnosis, it is your responsibility to check with your treating health care professional). yes no Do you currently have any condition or impairment (including, but not limited to, [i] any related to substance or alcohol abuse, or [ii] a mental, emotional, or nervous disorder or condition not reported above) which in any way affects, or if untreated could affect, your ability to perform any of the obligations and responsibilities of a practicing lawyer in a competent and professional manner? "Currently" means recently enough so that the condition could reasonably have an impact on your ability to function as a practicing lawyer. yes no If your answer to Question 18 (c) is affirmative, are the limitations or impairments caused by your condition or impairment reduced or ameliorated because you receive ongoing treatment (with or without medication) or because you participate in a monitoring program? yes no

(b)

(c)

(d)

If your answer to Question 18 (a), (b), (c), or (d) is affirmative, complete FORM A. Make copies of FORM A as needed.

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(e)

Within the past five years, have you ever raised the issue of consumption of drugs or alcohol or the issue of a mental, emotional, nervous, or behavioral disorder or condition as a defense, mitigation, or explanation for your actions in the course of any administrative or judicial proceeding or investigation; any inquiry or other proceeding; or any proposed termination or other disciplinary action by an educational institution, employer, government agency, professional organization, or licensing authority? yes no

If you answered in the affirmative to Question 18 (e), furnish a thorough explanation below. Include pertinent names, addresses, dates, and references to records, as appropriate.

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19. In your own handwriting, copy the following: I understand and acknowledge that my application for the Bar of Virginia is a continuing process and that I have an obligation to inform the Board of Bar Examiners, promptly and in writing, of any change in any of the information I have provided in this questionnaire and in any attachment hereto. I agree to cooperate fully by furnishing any supplemental information requested by the Board or the Character and Fitness Committee (and the agents thereof) so that the Board and the Committee will have all information relevant to my character and fitness to practice law when making a decision on my application. __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ ___________________________________ Signature of Applicant

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State of City/County of ________________________ , to-wit:

(Full Legal Name) I, (Full Legal Name) (County, State, Country)

(City) , born at (City)

In furtherance of my application for admission to the bar of Virginia, do hereby swear or affirm that I have read the foregoing document and have answered all questions fully and frankly. The answers are complete and true of my own knowledge. I hereby (a) authorize and request every person, firm, corporation, association, court, school, college, university, other educational institution, governmental and law enforcement and other agencies, including health care professionals and institutions, having control of any documents, records or other writing, or having other information pertaining to me (including but not limited to educational records as defined in 20 USC 1232g; confidential records; medical records and records concerning advice, care or treatment provided to me; files of bar associations or disciplinary agencies regarding charges or complaints filed against me, formal or informal, pending or closed, or other pertinent data) to furnish to the Virginia Board of Bar Examiners and its agents or representatives, including the National Conference of Bar Examiners, any such writings and information the Board believes may relate to my moral character, professional reputation, and/or fitness to engage in the practice of law, and to permit the Board and any of its agents or representatives to inspect and make copies of such documents, records, and other writings; (b) agree that all information provided by this application, and all other information received by the Board and believed by it to have a bearing upon my moral character, professional reputation, and/or fitness to engage in the practice of law, may be released by the Board at any time, and without liability to the Board, its members, agents, or other representatives, to any investigatory or regulatory body or agency having jurisdiction over admission to the bar or the discipline of lawyers, when such release is considered to be reasonably needed by such body or agency in response to its inquiry relating to my moral character, professional reputation, and/or fitness to engage in the practice of law; and (c) agree that the foregoing shall remain in effect for any future examination for which I may make application to the Virginia Bar. I release the National Conference of Bar Examiners and any person furnishing information in the course of the investigation of my character, professional reputation, and/or fitness to engage in the practice of law from all liability of any kind arising out of the furnishing of such information and documents, except when it is shown that such person was motivated by actual malice. Since this is a continuing questionnaire, I will submit such additional affidavits, documentation, or information as may be requested or as may be required by any change in my situation up to the date of my appearance before the Supreme Court of Virginia to be administered the oath of an attorney and counselor at law. I recognize and acknowledge that making a materially false statement in, or failing to disclose a material fact requested in connection with an application for admission to the bar is a violation of DR 1-101 of the Virginia Code of Professional Responsibility. A photocopy of the foregoing authorization shall be as valid as an original.

_______________________________________ Signature of Applicant Subscribed and sworn to or affirmed before me this ____ day of __________________, 19___. _______________________________________ Notary Public My commission expires: ____________________________ NOTARY SEAL (must be affixed)
Rev. 3/99

To be used with Questions 18(a), (b), (c), and (d) FORM A DESCRIPTION OF MENTAL HEALTH OR SUBSTANCE ABUSE CONDITION OR IMPAIRMENT

Full Name (First, Middle, Last) Date of treatment: From (Mo./Yr.) To (Mo./Yr.) Name of attending health care professional Health care professional's current address

(Street)! (City, State, Zip)

Telephone (

Name of hospital or institution Address

(Street)! (City, State, Zip)

Telephone (

Describe the condition or problem and any treatment or monitoring program.

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