UNITED STATES COURT OF APPEALS
FOR THE SEVENTH CIRCUIT
VOLUNTEER PANEL ATTORNEY QUESTIONNAIRE

1. Name _________________________________________

2. Address _______________________________________ ___________________________________________________ ___________________________________________________

3. Telephone _____________________________________

4. Social Security Number or Federal Employer Identification Number (necessary for tax purposes on vouchers in Criminal Justice Act cases only) ____________________________________

5. Bar Admissions: _________________________________ ___________________________________________________ ___________________________________________________

6. Law school attended and Date of Degree
__________________________________________________ __________________________________________________

7. Type of practice: ________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________

8. Are you currently a member of a panel maintained by a district court or Federal Public Defender office for appointment in district court proceedings? If "yes", please specify. ___________________________________________________________ ___________________________________________________________

____ I am interested in accepting Criminal Justice Act appointments from the Court of Appeals, under the guidelines set forth in the Act and the Seventh Circuit Plan for implementation of the Act.

I will accept appointment in 28 U.S.C. 2254 and 2255 appeals and in appeals in criminal proceedings from the following state(s):

____Illinois ____Indiana ____Wisconsin

____ I am interested in accepting appointment in non-Criminal Justice Act appeals, understanding that there is no statutory authority for the court to compensate me for my time and expenses.

I will accept appointment in the following types of non-Criminal Justice Act appeals:

____ non-prisoner civil rights____ Racial or sexual discrimination issues only ____ prisoner civil rights ____ United States agencies ____ 1st Amendment issues only ____ Black Lung

____ EEOC ____ Benefits Review Board____ National Labor Relations Board ____ Others

Signature ____________________________________Date_______________

Please return questionnaire to:

Donald J. Wall, Counsel to the Circuit Executive
U. S. Court of Appeals
219 South Dearborn Street, #2722
Chicago, IL 60604