Did you:
1. Review your application for completeness.
2. Sign the acknowledgement before a notary public or
commissioner of the superior court.
3. Attach all the required forms (your individual case may require
you to file forms in addition to those listed below):
1) Form M1 (Application)
2) Form M4 (Affidavit of Good Standing)
3) Form M5 (Certificate of Intention)
4) Form M6 (Summary sheet)
5) Form M7 (Return address labels)
6) Form M8 (Certificate of actual practice)
7) Form M9 (Status sheet)
Note: Forms M12 (personal references), M13 (affidavit of Connecticut
attorney), M14 (affidavit of attorney) and M20 (employer references)
should be sent directly to the CBEC by the affiants. If applicable, Form
M15 (affidavit of CT law school Dean) should be sent directly to the
CBEC by the affiant. Form M19 should come directly from the law
school with your transcript and law school application.
4. Enclose a certified check or money order in the amount of
$1800.00 payable to: Connecticut Bar Examining Committee. (Note:
Fees are not refundable!!)
The Connecticut Bar Examining Committee (CBEC) will conduct an
extensive background check for all applicants and reserves the right
to require applicants to submit fingerprints.
Send your application, required supporting documents and fee to:
Connecticut Bar Examining Committee
Motion Application Department
100 Washington Street, 1
st
Floor
Hartford, CT 06106-4411
Form M1
1 Rev. 02/2017
Form M1
Official Use Only
Connecticut Bar Examining Committee
DF
Application for Admission to Practice
Admission Without
As An Attorney in Connecticut
Examination
App #
A. Read the rules, regulations and instructions before completing this form.
B. Your answers must be typed and the application signed and notarized.
C. Be sure your name appears at the top of the Authorization and Release.
D. Pay the $1,800.00 fee by certified check or money order payable to “Connecticut Bar Examining Committee.”
The undersigned applies for admission to practice as an attorney in Connecticut, and in support of such application submits
the following sworn statement and attachments. This application is a continuing application and I will notify the
Bar Examining Committee of any changes in any information provided herein. I have read the Rules and
Regulations Governing Admission to the Bar and the Rules of Professional Conduct.
SECTION I. BIOGRAPHICAL INFORMATION
1.
Full Name
(Last)
(First)
(Middle)
2.
Name as you wish it to appear on your admission certificate:
Full Name
(Last)
(First)
(Middle)
3.
Place of Birth
Date of Birth
City/State/Country
mm/dd/yyyy
4a.
Social Security Number
4b.
NCBE Number
N
NA
[Pursuant to 42 USC §666(a)(13)(A) applicants are advised that providing their Social Security Number is required. The
information is requested pursuant to Practice Book Sec. 2-4 and Article III of the Regulations of the Bar Examining
Committee. The information will be used to match various records with your file.]
5.
Permanent/home address and telephone number (a street address is required; a P.O. box number is not acceptable):
Street
City
State
Zip Code
Telephone
6.
Business address and telephone number (a street address is required; a P.O. box number is not acceptable):
Business Name
Street
City
State
Zip Code
Telephone
7.
Correspondence address and telephone number:
Street
City
State
Zip Code
Telephone
Yes
No
8.
Have you ever made prior application for admission to the Connecticut bar (by examination, by transfer of
UBE score, or on motion without examination) or filed an application for registration as authorized house
counsel or foreign legal consultant? If so, give the month and year of each such application.
Form M1
2 Rev. 02/2017
9.
List all names you have been known by, including those listed in Questions 1 & 2, and provide the dates and places of
use for each. Do not list nicknames such as “Bob” for “Robert.”
Name
Reason for use
Dates of use
From
To
Places of use
Name
Reason for use
Dates of use
From
To
Places of use
Yes
10.
Check the appropriate box below:
I am a natural born citizen of the United States
I am a naturalized citizen of the United States. (Attach a copy of your naturalization certificate)
Date of naturalization: _______________________________
I am an alien lawfully residing in the United States. (Describe your immigration status and provide your alien
registration number and a copy of your resident alien card. If you do not have an alien registration number or
resident alien card, explain and attach a copy of your INS issued documents. )
______________________________________________________________________________
SECTION II. MULTISTATE PROFESSIONAL RESPONSIBILITY EXAMINATION
11.
Check the option below on which you intend to rely to fulfill the requirement of Article IV:
Check only one box.
I have taken/will take the Multistate Professional Responsibility Examination on _____________ and have
requested/will request that my score be sent to the Connecticut Bar Examining Committee.
I have completed/will complete a course on Professional Responsibility/Legal Ethics on _____________ at
a law school approved by the Connecticut Bar Examining Committee
Form M1
3 Rev. 02/2017
SECTION III. AFFIDAVITS
12.
List the names and complete addresses of three persons unrelated to each other with whom you are personally
acquainted and who are not related to you by blood or marriage. Personal references in this question may
NOT be the same people supplying employer references required in Question 20. You must provide a Form
M12 to each person named below for completion and transmittal to the Bar Examining Committee.
Name
Street
City
State
Zip Code
Name
Street
City
State
Zip Code
Name
Street
City
State
Zip Code
13.
List the names and complete addresses of two Connecticut attorneys, not related to you by blood or marriage,
who have been admitted to the Connecticut bar for at least five years and will supply affidavits (Forms M13)
that will certify facts relating to your good moral character and fitness to practice law.
Name
Street
City
State
Zip Code
Name
Street
City
State
Zip Code
14.
List the names and complete addresses of two attorneys, not related to you by blood or marriage, who have
been admitted to practice law for at least five years and will supply affidavits (Forms M14) that will certify facts
relating to your practice of law, good moral character and fitness to practice law.
Name
Street
City
State
Zip Code
Name
Street
City
State
Zip Code
15.
List the name of the accredited law school at which you are a full-time faculty member or a full-time clinical
fellow, the Dean of which will supply an affidavit (Form M15) that will certify facts relating to your
employment relationship. Please note: Form M15 must be supplied in addition to Form M20.
NA
Name
City, State
Form M1
4 Rev. 02/2017
SECTION IV. RESIDENCES
16.
List in chronological order (from oldest to most recent) every residence, permanent or temporary, for more
than thirty days, since your eighteenth birthday or for the last ten years, whichever is shorter. Attach a Form
M2 with additional residences if necessary.
From:
To:
Street
City
State
Zip Code
From:
To:
Street
City
State
Zip Code
From:
To:
Street
City
State
Zip Code
From:
To:
Street
City
State
Zip Code
From:
To:
Street
City
State
Zip Code
From:
To:
Street
City
State
Zip Code
From:
To:
Street
City
State
Zip Code
Form M1
5 Rev. 02/2017
SECTION V. EDUCATION
Yes
No
17.
Have you ever been expelled, dropped, suspended, warned, placed on scholastic or disciplinary probation
or been the subject of or party to any disciplinary proceeding by any college, university or law school? If
so, explain on Form 2.
Yes
No
18.
Have you ever been absent from any post-secondary educational institution for more than ten consecutive
days, other than for regularly scheduled school vacations? If so, explain on Form M2.
19.
List in chronological order (from oldest to most recent) all colleges and universities attended (INCLUDING
LAW SCHOOLS). If no degree was received, explain. Each school must submit an official, final transcript
directly to the Bar Examining Committee (a student copy is NOT acceptable). Each law school must also
submit Form M19 directly to the Bar Examining Committee with the official, final transcript and a copy of
your application for admission to that law school attached.
School
Degree
City
State
Zip Code
From
To
Explanation for no degree:
School
Degree
City
State
Zip Code
From
To
Explanation for no degree:
School
Degree
City
State
Zip Code
From
To
Explanation for no degree:
School
Degree
City
State
Zip Code
From
To
Explanation for no degree:
School
Degree
City
State
Zip Code
From
To
Explanation for no degree:
School
Degree
City
State
Zip Code
From
To
Explanation for no degree:
School
Degree
City
State
Zip Code
From
To
Explanation for no degree:
School
Degree
City
State
Zip Code
From
To
Explanation for no degree:
Form M1
6 Rev. 02/2017
SECTION VI. EMPLOYMENT AND LAW PRACTICE
20.
Beginning with your sixteenth birthday or for the last ten years, whichever is shorter, list in chronological
order (from oldest to most recent) the name of each employer. Include any periods of self-employment or
unemployment. You must send a Form M20 to each employer named below covering the past five years for
completion and transmittal to the Bar Examining Committee. Exceptions to this are set forth in the
instructions for Form M20. For type of position use the following: P = Paid; CU = For Academic Credit
and Unpaid; CP = For Academic Credit and Paid; or V = volunteer. Attach Form M20A if you need to list more
than five employers.
From
To
Name
Street
City
State
Zip Code
Position held
Type
Supervisor
Type of business
Reason for leaving
From
To
Name
Street
City
State
Zip Code
Position held
Type
Supervisor
Type of business
Reason for leaving
From
To
Name
Street
City
State
Zip Code
Position held
Type
Supervisor
Type of business
Reason for leaving
From
To
Name
Street
City
State
Zip Code
Position held
Type
Supervisor
Type of business
Reason for leaving
From
To
Name
Street
City
State
Zip Code
Position held
Type
Supervisor
Type of business
Reason for leaving
Yes
No
21.
Have you ever been discharged or terminated by an employer? If so, explain on Form M2.
Yes
No
22.
Have you ever resigned or been requested to resign in lieu of impending or anticipated disciplinary action by
an employer? If so, explain on Form M2.
Form M1
7 Rev. 02/2017
Yes
No
23.
Have you ever been absent from a job for more than ten consecutive work days, other than regularly scheduled
vacations? If so, explain on Form M2.
24.
List below all applications for admission to the bar and/or to sit for the bar examination filed in a jurisdiction
other than Connecticut. This must also include (1) applications which you have filed or intend to file to sit for
an upcoming bar examination, (2) registration as a law student, (3) an application for reinstatement, (4) any
application subsequently withdrawn, (5) applications for authorized house counsel and (6) applications for
foreign legal consultant. Submit a copy of each application filed within the last ten years. If a copy of an
application is not available, you must submit a letter from the appropriate authority attesting to that fact.
Jurisdiction
Date Filed
Type:
Exam Motion/reciprocity Law Student Registration Reinstatement Other
Current status (e.g.: pending, pass, fail, withdrawn)
Jurisdiction
Date Filed
Type:
Exam Motion/reciprocity Law Student Registration Reinstatement Other
Current status (e.g.: pending, pass, fail, withdrawn)
Jurisdiction
Date Filed
Type:
Exam Motion/reciprocity Law Student Registration Reinstatement Other
Current status (e.g.: pending, pass, fail, withdrawn)
25.
List the jurisdictions in which you are or have ever been a member of the bar, including any federal court
admissions. Submit a certificate of good standing for each. Original letters of good standing must be received
in the CBEC Administrative Office no later than thirty (30) days after issuance. If you are not in good
standing, explain on Form M2.
Jurisdiction
Date of admission
License Number
Good standing
Yes
No
Jurisdiction
Date of admission
License Number
Good standing
Yes
No
Jurisdiction
Date of admission
License Number
Good standing
Yes
No
Yes
No
26.
Have you ever been reprimanded, suspended, disbarred or otherwise disciplined, or are there any charges or
complaints pending against you as an attorney, or have you ever been accused of the unauthorized practice of
law, or have you ever resigned or been requested to resign from the bar in lieu of impending or anticipated
disciplinary action? If so, explain on Form M2.
Yes
No
27.
Have you been entitled to practice law in each of the jurisdictions specified in Question 25 above and before
each court continuously from the date you first became entitled until the date hereof? If not, state the dates
during which you have not been so entitled, the nature of the disqualification, and the name and address of the
person or authority in possession of the record thereof.
Jurisdiction
Dates of disqualification
From
To
Nature of disqualification
Name of recordholder
Address of recordholder
Form M1
8 Rev. 02/2017
28.
State the exact names and locations of courts before which your practice of law for the last ten years was
chiefly conducted and the general nature of cases tried, if any, or the law schools (name and location) at which
you currently teach or have taught law, including supervision of law students within a clinical program, for the
last ten years.
29.
Describe in detail the nature of your practice and the extent of same, or the titles of the classes that you
currently teach or have taught, including clinical program(s) for which you currently supervise or have
supervised law students, at a law school listed above.
SECTION VII. MILITARY SERVICE
Selective Service Registration. You can obtain information on the registration requirements and obtain your registration
number at http://www.sss.gov. In brief, men born from March 29, 1957 to December 31, 1959 were never required to register
because the registration program was not in operation at the time they turned 18. The requirement to register was reinstated in
1980 and applies to all men born on or after January 1, 1960.
Yes
No
30.
Have you registered under the Selective Service Act?
If Yes, list registration number
If No, state reason
Female Other
Yes
No
31.
Are you or have you ever been a member of the armed forces of the United States (including the National
Guard or any reserve component)? If so, submit a Report of Separation DD214 or its equivalent for each
period of active duty. Also complete Form M31 and submit it with your application.
Branch of service
Highest rank
Dates
From
To
Type of discharge
Branch of service
Highest rank
Dates
From
To
Type of discharge
Branch of service
Highest rank
Dates
From
To
Type of discharge
Form M1
9 Rev. 02/2017
SECTION VIII. GENERAL QUESTIONS
Yes
No
32.
Have you failed to file any local, state or federal income tax return as required by law or failed to pay any taxes
when due? If yes, give full details on Form M2 and furnish documentation showing that taxes are current.
Yes
No
33.
Have you ever been offered or been granted immunity, or have you ever testified or been called as a witness
in any criminal action or proceeding in which you were not a party? If so, explain on Form M2.
Yes
No
34.
Have you ever applied for or held a license or permit, other than as an attorney at law, the procurement of
which required proof of good character? If so state the name of authority to whom the application was made,
the date granted or denied and the current status of that license or permit.
Type of license/permit
Name of authority
Granted
Yes
No
Date
Current status
Type of license/permit
Name of authority
Granted
Yes
No
Date
Current status
Yes
No
35.
Have you had any license or permit suspended or revoked because of unprofessional conduct? If so, explain on
Form M2.
Yes
No
36.
Have you ever been bonded?
Yes
NA
No
37.
If so, have you ever been refused a bond or has anyone ever sought to recover on or cancel such bond? If so,
explain on Form M2.
Yes
No
38.
Within the past five years, have you engaged in any conduct that: (1) resulted in an 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 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,
explain on Form M2 and include any asserted defense or claim in mitigation or as an explanation of your
conduct and, if applicable to your explanation, Form M40A.
Yes
No
39.
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 so, explain on Form M2.
Form M1
10 Rev. 02/2017
Question 40 – 41 address mental health and chemical or psychological dependency matters. The Committee asks these
questions because of its responsibility to protect the public by determining the current fitness of an applicant to practice
law, and the purpose of these questions is to determine an applicant’s current fitness to practice law. This information,
along with all other information, is treated confidentially by the Committee and the Administrative Office. Each applicant
is considered on an individual basis. The mere fact of treatment for mental health problems or chemical or psychological
dependency is not, in and of itself, a basis on which an applicant is ordinarily denied admission to the Connecticut bar.
The Connecticut Bar Examining Committee regularly recommends licensing of individuals who have demonstrated
personal responsibility and maturity in dealing with mental health and chemical or psychological dependency issues. The
Committee encourages applicants who may benefit from treatment to seek it, and the Committee views such treatment as
a positive factor in evaluating an application. As indicated in the Rules, all proceedings conducted pursuant to the Rules
and Regulations are confidential.
On occasion, a license may be denied when an applicant’s ability to function is impaired in a manner that indicates that
the applicant is currently unfit to practice law at the time the licensing decision is made, or when the applicant
demonstrates a lack of candor and/or credibility by his or her response. Protection of the public that will receive legal
services underlies the licensing responsibilities assigned to the Committee. Furthermore, each applicant is responsible for
demonstrating that he or she possesses the qualifications necessary to practice law. Your response may include
information as to why, in your opinion or that of your treatment provider, your condition will not affect your ability to
practice law in a competent and professional manner.
The Connecticut Bar Examining Committee does not, by its questions, seek information that is characterized as situational
counseling, such as stress counseling, domestic counseling, and grief counseling. Generally, the Committee does not view
these types of counseling as germane to the issue of whether an applicant is qualified to practice law.
If you answer “YES” to Question 40, complete Forms M40A and M40B. Make as many copies of the forms as you need to
describe the events.
Yes
No
40.
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 a material way affects your ability to
practice law in a competent, ethical, and professional manner? “Currently” means recently enough that the
condition or impairment could reasonably affect your ability to function as a lawyer. If your answer is yes,
continue to Question 41 and complete Forms M40A and M40B. If your answer is no, continue to Question 42.
Yes
NA
No
41.
If your answer to Question 40 is yes, 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?
SECTION IX. CREDIT
Questions 42 and 43 are limited to the last ten years
Yes
No
42.
Are you presently in arrears or have you ever been in default in the performance of the obligation on a student
loan? If so, list each such loan, the name of the creditor, account number, amount owed and the steps you
have taken to bring the account up to date.
Creditor
Account number
Amount
Steps to bring current
Creditor
Account number
Amount
Steps to bring current
Creditor
Account number
Amount
Steps to bring current
Form M1
11 Rev. 02/2017
Yes
No
43.
Has judgment ever entered against you in favor of a creditor? If so, submit a copy of the complaint, answer,
judgment and satisfaction of judgment.
Creditor
Amount
Judgment satisfied
Yes
No
Forum
Creditor
Amount
Judgment satisfied
Yes
No
Forum
SECTION X. CIVIL PROCEEDINGS
Questions 44 - 48 are limited to the last ten years
Yes
No
44.
Are you in arrears or default in the performance of any court ordered duty or obligation? If so, submit a copy
of the order and on Form M2 an explanation of the steps you have taken to remedy the arrearage or default.
Yes
No
45.
Are you presently, or have you ever been, in arrears or default in the performance of any court approved
agreement, judgment or court order concerning child support? If so, supply all documentation pertaining
thereto and a statement on Form M2 outlining the steps you are presently taking to remedy such arrearage or
default.
Yes
No
46.
Have you ever filed a grievance against an attorney or a judge? If so, explain on Form M2.
Yes
No
47.
Have you ever been a defendant in any civil proceeding in which allegations of fraud, misrepresentation or
other improper conduct were made against you? If so, provide the information below and submit a copy of the
complaint, answer, judgment and any pending motions.
EXAMPLE
A.
Title of case
Jones v. Smith
B.
Name of forum
Hartford Superior Court
C.
Docket number
CV-02-001
D.
Date filed
01 Jan 02
E.
Nature of case
Personal injury
F.
Your position in case
Defendant
G.
Your attorney
Jane Doe
H.
Opposing attorney
Elizabeth Green
I.
Current status or disposition
Verdict for plaintiff
PHOTOCOPY AS NECESSARY
A.
Title of case
B.
Name of forum
C.
Docket number
D.
Date filed
E.
Nature of case
F.
Your position in case
G.
Your attorney
H.
Opposing attorney
I.
Current status or disposition
Form M1
12 Rev. 02/2017
A.
Title of case
B.
Name of forum
C.
Docket number
D.
Date filed
E.
Nature of case
F.
Your position in case
G.
Your attorney
H.
Opposing attorney
I.
Current status or disposition
Yes
No
48.
Except as provided in Questions 44 and 47 above, have you ever been a party to any civil or administrative
proceeding or has any civil or administrative proceeding been instituted by you, on your behalf or against you
including, but not limited to, suits in equity, actions at law, suits or petitions in bankruptcy, statutory
proceedings, competency or commitment proceedings, divorce, civil restraining orders, guardianship,
probate, paternity, any other civil and administrative proceeding, or any proceeding before a government
agency, professional organization, licensing authority, the Law School Admission Council (LSAC), the
National Collegiate Athletic Association (NCAA) or similar entity, or through online dispute resolution?
A.
Title of case
B.
Name of forum
C.
Docket number
D.
Date filed
E.
Nature of case
F.
Your position in case
G.
Your attorney
H.
Opposing attorney
I.
Current status or disposition
A.
Title of case
B.
Name of forum
C.
Docket number
D.
Date filed
E.
Nature of case
F.
Your position in case
G.
Your attorney
H.
Opposing attorney
I.
Current status or disposition
Form M1
13 Rev. 02/2017
SECTION XI. CRIMINAL AND MOTOR VEHICLE PROCEEDINGS
The Connecticut Bar Examining Committee (CBEC) will conduct an extensive background check for all applicants
and reserves the right to require applicants to submit fingerprints.
Yes
No
49.
Have you ever been convicted of a criminal charge, been acquitted by reason of mental disease or defect,
entered a pretrial diversion program or been the respondent in a criminal protective order or a family violence
temporary restraining order? If so, submit a copy of the arrest report and all other documents relating to each
conviction, acquittal by reason of mental disease or defect, pretrial diversion program, criminal protective
order or family violence temporary restraining order. Submit an affidavit reciting in detail the facts and
circumstances of each reported event. If you are uncertain as to whether a matter ought to be disclosed in
accordance with this question, we advise you to disclose the matter fully.
SAMPLE
A.
Title of case
State v. Smith
B.
Name of forum
Hartford Superior Court
C.
Docket number
CR-02-001
D.
Date of conviction/disposition
01 Jan 02
E.
Conviction offense
Larceny 3
F.
Initial charge (if different)
Grand theft auto
A.
Title of case
B.
Name of forum
C.
Docket number
D.
Date of conviction/disposition
E.
Conviction offense
F.
Initial charge (if different)
Yes
No
50.
Are there any criminal charges pending against you? If so, submit a copy of the arrest report and all other
documents related to each pending charge. Submit an affidavit reciting in detail the facts and circumstances
related to each pending charge.
SAMPLE
A.
Title of case
State v. Smith
B.
Name of forum
Hartford Superior Court
C.
Docket number
CR-02-001
D.
Date of arrest
01 Jan 02
E.
Date of trial
01 Feb 02
F.
Offense charged
Grand theft auto
A.
Title of case
B.
Name of forum
C.
Docket number
D.
Date of arrest
E.
Date of trial
F.
Offense charged
Yes
No
51.
Within the last five years, have you been charged with reckless driving, evading responsibility, driving under
the influence (DUI) or driving while intoxicated (DWI)? On Form M2 submit a narrative of the events related
to each charge.
SAMPLE
A.
Jurisdiction
Connecticut
B.
Date of charge
01 Jan 02
C.
Docket number (if any)
n/a
D.
Initial charge
DWI
E.
Current status or disposition
reckless driving
Form M1
14 Rev. 02/2017
A.
Jurisdiction
B.
Date of charge
C.
Docket number (if any)
D.
Initial charge
E.
Current status or disposition
A.
Jurisdiction
B.
Date of charge
C.
Docket number (if any)
D.
Initial charge
E.
Current status or disposition
52.
List every jurisdiction and submit a certified driving record (or “no record” or “clearance” letter) from the
Department of Motor Vehicles from each of the following:
1. Every jurisdiction in which you hold a motor vehicle driver’s license or operator’s permit;
2. Any jurisdiction during the past five years in which you have resided for sixty days or more, whether or not
you ever held a driver’s license or operator’s permit in that jurisdiction; AND
3. Any jurisdiction in which your driving privileges have ever been suspended or revoked.
Original certified driving records and no record or clearance letters must be received in the CBEC
Administrative Office no later than sixty (60) days after issuance for jurisdictions in which you are currently
licensed and/or currently reside (whether permanent or temporary).
On Form M2 provide a narrative for each suspension or revocation.
SAMPLE
A.
Jurisdiction
Connecticut
B.
X License or permit held Resided for 60 days or more X Driving privileges suspended or revoked
B.
Date held
01 Jan 80 – present
C.
Type of license/permit
passenger car and motorcycle license
D.
Current status
active
E.
Ever revoked/suspended
Yes
x
No
Suspended from
9/1/01
To
12/1/01
A.
Jurisdiction
B.
License or permit held Resided for 60 days or more Driving privileges suspended or revoked
C.
Date held
From
To
D.
Type of license/permit
E.
Current status
F.
Driving privileges ever
revoked/suspended
Yes
No
Suspended from
To
A.
Jurisdiction
B.
License or permit held Resided for 60 days or more Driving privileges suspended or revoked
C.
Date held
From
To
D.
Type of license/permit
E.
Current status
F.
Driving privileges ever
revoked/suspended
Yes
No
Suspended from
To
Form M1
15 Rev. 02/2017
SECTION XII. ACKNOWLEDGEMENTS
53.
Each applicant shall read and initial each acknowledgement below.
Please use BLUE ink.
_____I hereby acknowledge that this application for admission to the Connecticut bar is a continuing application and that I have an
obligation to keep my responses to the questions current, complete and correct by filing timely amendments until the date of my
admission to the bar of Connecticut.
_____I hereby acknowledge that an amendment is considered timely when made within thirty days of any occurrence that would
change or render incomplete any answer on my bar application.
_____I hereby acknowledge that any false, misleading or evasive response on my bar application is inconsistent with the truthfulness
and candor required of a practicing attorney and may be grounds for a finding of a lack of the requisite good moral character
and fitness for membership in the Connecticut bar.
Form M1
16 Rev. 02/2017
SECTION XIII. AUTHORIZATION AND RELEASE
Full Name
Social Security Number
Date of Birth
As part of my application for admission to the bar of the state of Connecticut, I consent to have an investigation made as to my
moral character, professional reputation and fitness to practice law. I agree to provide any further information that may be required
in reference to my past record. I further agree to execute such further releases as may be requested by the Connecticut Bar
Examining Committee. I understand that the contents of my character report are confidential and that I will not be entitled to
receive a copy of the report, including but not limited to, character affidavits submitted in support of this application, or to know its
contents, unless my file is referred to the Connecticut Bar Examining Committee for character and fitness investigation.
I hereby authorize and request every person, firm, company, corporation, government agency, law enforcement agency, court,
association or institution having control of any documents, records, or other information pertaining to me, to furnish to the
Connecticut Bar Examining Committee any such information, including documents, records, bar association files regarding charges
or complaints filed against me, including any complaints erased by law, whether formal or informal, pending or closed, or any other
pertinent data; and to permit the Connecticut Bar Examining Committee or any of its agents or representatives to inspect and make
copies of such documents, records, or other information. The records, however, will not include any information with respect to a
juvenile offense.
I authorize the National Personnel Records Center in St. Louis, MO or other custodian of my military record to release to the
Connecticut Bar Examining Committee information or photocopies from my military personnel and related medical records
including a copy of my Report of Separation DD214.
I hereby release, discharge and exonerate the Connecticut Bar Examining Committee, its authorized representatives and any
person furnishing information authorized by this release from any and all liability of every nature and kind arising out of the
furnishing or inspection of such documents, records and other information or the investigation made by the Connecticut Bar
Examining Committee.
SECTION XIV. ACKNOWLEDGEMENT OF APPLICATION and AUTHORIZATION AND RELEASE
Dated at
City
State
on
____________________________________________
(Signature of Applicant)
State of
County of
On this the _________________ day of ____________________, 20 ___ before me, _____________________________
(day)
(month)
(notary public/commissioner of the superior court)
personally appeared ________________________________________, known to me (or satisfactorily proven) to be the person
(applicant)
whose name is subscribed to the within instrument and acknowledged that he/she executed the same for the purposes therein
contained and that his/her responses are true to the best of his/her knowledge.
In witness whereof I hereunto set my hand.
____________________________________________
(notary public/commissioner of the superior court)
