| General Information |
| Personal Information |
| Please enter your personal information. |
| Full Name | John Smith |
| Social Security Number | ***-**-**** |
| NCBE Number | N10000000 |
| Contact Information |
| Present Mailing Address |
| Street or P.O. Box # | 3855 Lake Clearwater Place |
| Apt. # or Address 2 | Apt. 222 |
| County | Marion |
| City | Sarasota |
| State | Florida |
| ZIP Code | 90210 |
| Country | United States of America |
| Permanent Mailing Address |
| Street or P.O. Box # | 3855 Lake Clearwater Place |
| Apt. # or Address 2 | Apt. 222 |
| City | Sarasota |
| State | Florida |
| zip | 90210 |
| Preferred Contact Number | (812) 111-5100 |
| Alternate Number | (812) 111-5101 |
| Present Mailing Address is valid until |
| Home Telephone Number | (812) 111-5100 |
| Work Telephone Number | (812) 111-5102 |
| E-Mail Address | sample@email.com |
| Bar Admission |
| Other Jurisdictions |
| 7 | Have you ever applied for admission to practice law by motion, by reciprocity, by diploma privilege or by taking a bar exam in any other jurisdiction? (Include any pending or prior applications. Do not include this application.)
Please upload a Certificate of Good Standing if admitted |
| Failed Applications |
| 8 | Applicant failed to obtain a passing grade on the following examinations given by the Indiana State Board of Law Examiners |
| Exam Date |
| Employment |
| Employment |
| 9 | Since the filing of my original application, I have been employed. |
| Employer Name |
| Address 1 |
| Address 2 |
| City |
| State |
| Zip Code |
| Country |
| Phone # of Supervisor or Employment Verification Contact |
| Email Address of Supervisor or Employment Verification Contact |
| Type of Work | ||
| Date Started |
| Date Ended |
| Reason for leaving the job | ||
| If the reason for leaving the job was anything but voluntary, provide a detailed written description of the facts and circumstances relating to your leaving the job. UPLOAD copies of any paperwork or documentation that is related to such situations. |
| Description | ||
| Driver License |
| Driver License |
| Have you ever held a Drivers License? |
| 10 | For each state in which you have held a license to operate a vehicle in since the date of your original application, please provide the following information. |
| Include the state in which you held a driver's license at the time of your original application. |
| State |
| Date License Held From |
| Date License Held To |
| Other Questions |
| Other Questions |
| SINCE THE FILING OF YOUR ORIGINAL APPLICATION |
| 11 | Since filing your original application have you 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 an explanation for your actions in the course of any administrative or judicial proceeding or investigation, any inquiry or other proceeding, or any proposed termination by an educational institution, employer, government agency, professional organization or licensing authority? |
| If you answered "yes" furnish a through and complete factual explanation. Include pertinent names, addresses, dates and references to records, as appropriate. If you have additional documentation, you must upload this documentation after submission of your application. | ||
| 12 | Since filing your original application, have you been convicted, arrested or accused of violations of law or the subject of any investigation of a violation of law, including, but not limited to, all traffic offenses, felonies, misdemeanors, infractions and anything else? |
| Note: Indiana's expungement statute, Ind. Code 35-38-9, does not apply to the State Board of Law Examiners for purposes of determining whether an applicant possesses good moral character for admission to the bar. You are, therefore, required to include and disclose all matters, including any arrests or convictions that may have been expunged, dismissed or otherwise set aside. |
| IF YOU ANSWER YES TO QUESTION 12, YOU MUST COMPLETE A FORM B-3 FOR EACH INSTANCE. |