Missouri Board of Law Examiners - Print Application Forms

Application for Character & Fitness Report

General Information

Personal

Prefix

*Social Security Number

***-**-****

*Furnishing your SSN is voluntary pursuant to the Federal Privacy Act of 1974. Your SSN will be used to expedite the Board's investigation and to avoid errors of identity.

Full Name

John Smith

Date of Birth

January 10, 1961

Place of Birth (City/State/Country)

Carlisle

Contact Information

C	Telephone numbers and email address where you can be contacted about this application:

Home Phone

(812) 111-5100

Cell Phone

(812) 111-5101

Office Phone

(812) 111-5102

Other Phone

(812) 121-5203

E-mail Address

sample@email.com

Mailing address where we should send communications related to your application:

Street Address Line 1

3855 Lake Clearwater Place

Street Address Line 2

Apt. 222

PO Box

City

Sarasota

State/Province

Florida

Zip/Postal Code

90210

Country

United States of America

Contact person that can be used in case the board cannot get into contact with you (parent, close friend, etc.). This does not provide authorization for this individual to obtain information regarding your application. This information will only be used in the event that the board has unsuccessfully tried to communicate directly with you.

Name

Street Address Line 1

Street Address Line 2

PO Box

City

State/Province

Zip/Postal Code

Country

Telephone

Other Names

Have you ever been known by any other name (include maiden names, nicknames, etc.)?

If YES, list all names since age 18 and corresponding dates (including maiden name):

First

Middle

Last

From Mo/Yr

To Mo/Yr

Please check the dates you provided

Provide a detailed explanation

Marriage

Are you married?

Spouse's Full Name

Date of Marriage

Father

Father's Name

Is your father deceased?

Phone Number

Street Address

City

State/Province

Zip/Postal Code

Country

Mother

Mother's Name

Is your mother deceased?

Phone Number

Street Address

City

State/Province

Zip/Postal Code

Country

Citizenship

Are you a citizen of the United States?

Provide a CERTIFIED birth certificate, a CERTIFIED Consular Report of Birth, a copy of your Certificate of Naturalization, or a copy of your Certificate of Citizenship.

Are you a lawful permanent resident of the United States?

Provide a copy of both sides of the U.S. Citizenship and Immigration Services (USCIS) document evidencing your status. We will verify your status with USCIS.

Are you a nonimmigrant alien authorized to work lawfully in the United States?

Provide a copy of both sides of the U.S. Citizenship and Immigration Services (USCIS) document evidencing your status. We will verify your status with USCIS.

Rule 8.03(a)(4) requires that you be a U.S. citizen, a lawful permanent resident, or an alien authorized to work lawfully in the U.S. before you can be admitted to the bar. You must meet this requirement within one year after the date of written notification that you passed the bar examination or else your exam scores will be voided as provided in Rule 8.03(c).

Driver License

2	List in chronological order every state where you have held a driver's license during the past five years.

State/Province

License Number

Expiration

You must provide an official driver record from each state listed above. Contact the driver records department in each state and request a driver's record that includes your history of any traffic violations and administrative actions. Upload the record by clicking on the "Upload New Document" button in the bottom right corner of your user home page, or mail the record to Missouri Board of Law Examiners, P.O. Box 104236, Jefferson City, MO 65110-4236.

Have you made this request to each state?

Addresses for Past 3 Years

3.A	List every permanent or temporary physical address where you have resided for a period of a month or longer during the past three years. List in reverse chronological order, starting with your current residence.

From Mo/Yr

To Mo/Year

Street Address

City

State/Province

Zip/Postal Code

Country

Earlier Addresses

3.B	List the City and State of every permanent or temporary physical address where you resided for a period of a month or longer during the time period from age 18 until three years prior to this application. List in reverse chronological order.

From Mo/Year

To Mo/Year

City

State/Province

Country

Education

Colleges

4.A

List the names of the colleges and universities other than law schools that you have attended, the location (including the name of the campus if the school has more than one), the dates of attendance, and the degree received. Mark "ND" if you did not receive a degree. List schools in chronological order of attendance.

College

City

State/Province

Zip/Postal Code

Country

From Mo/Yr

To Mo/Yr

Degree (Mark "ND" if no degree.)

Law Schools

4.B	List the names of all law schools that you have attended, the location (including the name of the campus if the school has more than one), the dates of attendance, and the degree received. Mark "ND" if you did not receive a degree. List schools in chronological order of attendance.

ABA Approved Law School

NonABA Law School

City

State/Province

Zip/Postal Code

Country

From Mo/Yr

To Mo/Yr

Degree (Mark "ND" if no degree.)

Misconduct

Regardless of whether the record has been expunged, cancelled, annulled, or whether no record was ever made, have you ever been suspended, placed on probation, expelled, warned, reprimanded, or disciplined formally or informally for any academic or non-academic reason at any college, university, or law school?

If YES, provide a copy of all relevant documentation and list the following: (1) Date(s); (2) Detailed explanation of the circumstances surrounding each incident; (3) Name, mailing address, and telephone number of the department or office that would have the most complete information regarding the matter; and (4) Provide the board with a copy of all correspondence between you and the school regarding the incident.

Date of incident

	Provide a detailed explanation

Name of College, University, or Law School

Department or Office

Mailing Address

City

State/Province

Zip/Postal Code

Country

Telephone Number

E-mail Address

5.A

Were you ever the subject of a complaint, probable cause hearing or other initial inquiry for any academic or non-academic reasons at any college, university, or law school?

Date of incident

	Provide a detailed explanation

Name of College, University, or Law School

Department or Office

Mailing Address

City

State/Province

Zip/Postal Code

Country

Telephone Number

E-mail Address

Absences

Have you ever been absent from school for 30 or more consecutive days, other than regularly scheduled vacations and semester breaks?

If YES, provide: (1) dates of absence; (2) a detailed explanation; (3) name, mailing address, and telephone number of the college, university, or law school.

Name of College, University, or Law School

Department or Office

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone Number

E-mail Address

From Mo/Yr

To Mo/Yr

	Provide a Detailed Explanation

Employment

Licensed Attorney

In answering Questions 7.A. and 7.B. employment is considered to be part-time and full-time employment, self-employment, internships and externships (paid or unpaid), clerkships, volunteer work, military service, and temporary or seasonal jobs. If you were assigned to a job by a temporary agency, list the name, mailing address and telephone number of the temporary agency. Do NOT furnish your own name or the name of someone related to you by blood or marriage as a verifying reference for any employment or self-employment. Disclose military service under Question 7.C.

7.A

Since the time you became admitted in any jurisdiction, have you been or are you currently employed as a licensed attorney? Do not include in response to this question work as a law clerk, paralegal, or other non-attorney positions.

Complete a FORM 7.A. for each employment.

Other Employment

7.B

For the ten year period preceding this application or since the age of 18, whichever is shorter, have you had or do you currently have any employment other than that listed in the preceding question? Include non-attorney law-related employment here (e.g., paralegal, law clerk, externships, internships, etc.).

Complete a Form 7.B. for each employment.

Military

7.C

Have you ever been a member of the armed forces of the United States, its reserve components, or the National Guard? (Do not include ROTC.)

If Yes, complete FORM 7.C and provide a copy of all of your Reports of Separation (e.g., DD FORM 214-Member Copy #4, NGB Form 22, etc.). The Report of Separation must indicate your character of service.

Unemployment

7.D

For the ten year period preceding this application or since age 18, whichever is shorter, have you ever been unemployed for a period of 30 days or more? Account for all periods of unemployment regardless of the reason, including periods when you were a full-time student.

Bar Admission

Applications

8.A

Have you ever applied to sit for the bar examination or applied to the bar admissions authority in any U.S. jurisdiction (state, territory, or D.C.) or foreign jurisdiction for admission on examination, on motion, or any other basis that DID NOT RESULT, OR HAS NOT RESULTED, in your admission to practice law in that jurisdiction? (Include any application to pre-register as a law student).

If YES, list every jurisdiction to which you have applied and answer these questions for each time you applied (multiple applications to the same jurisdiction require separate entries). If you applied in New York, indicate to which Judicial Department (First, Second, Third, or Fourth).

Name of Jurisdiction

Application Type

Describe

Date application submitted (Mo/Yr)

Date exam taken (Mo/Yr)

If not admitted or approved, indicate reason:

	If you withdrew your application or your application was denied, explain in detail the reason for withdrawal or denial.

A copy of your character and fitness application, and any amendments made, or letter from the admission agency stating a copy is not available must be provided. Mail the application to: Missouri Board of Law Examiners, P.O. Box 104236, Jefferson City, MO 65110-4236.

Have you requested a copy of your application be sent to the board?

8.B

In connection with any application, regardless of admission status, were you required to appear for a hearing or inquiry before any board, committee, or admissions authority?

If Yes, provide: (1) Name of the jurisdiction (2) Date of the hearing or inquiry; (3) Detailed explanation of the reasons or grounds for the inquiry; and (4) provide a copy of the correspondence regarding the final determination of the inquiry.

Name of jurisdiction

Date of hearing or inquiry

	Provide a detailed explanation

License & Registration

9.A

Have you ever been admitted to the bar, or registered as in-house counsel, or registered as a legal services attorney in any U.S. jurisdiction (federal, state, territory, or D.C.) or in any foreign jurisdiction? (Exclude pro hac vice admissions and exclude law student registration.)

If YES, list every jurisdiction in which you currently are, or ever have been, admitted or registered.

NOTE: You must provide a Certificate of Status or Certificate of Good Standing from the licensing authority and a Disciplinary History Statement that includes a statement regarding any current or pending charges from the disciplinary authority of each U.S. or foreign jurisdiction in which you currently are, or ever have been, admitted.

Has your license to practice law in any jurisdiction ever been limited, restricted, monitored, or conditioned upon compliance with any terms or conditions?

If YES, provide a copy of any documents that set out the terms, conditions, limitations, and/or restrictions and list the following: (1) dates during which it has been limited, restricted, monitored, or conditioned; (2) nature of the limitation, restriction or conditions; and (3) name and address of the regulatory agency.

Begin Date

End Date

Agency

Mailing Address

City

State/Province

Zip/Postal Code

	Provide a detailed explanation

Professional Misconduct

Attorney Discipline

10.A

As an attorney, have you ever been disbarred, suspended, censured, placed on probation, reprimanded, disciplined, or allowed to resign or offered diversion in lieu of disciplinary action? Include matters where discipline was stayed or held in abeyance subject to a diversion or other agreement and include matters deemed confidential or closed.

10.B

Have you ever been the subject of any formal or informal charges, complaints, or grievances concerning your conduct as an attorney, including any now pending? Disclose all matters, even if the outcome was favorable, it was dismissed, no discipline was imposed, discipline was stayed or held in abeyance subject to a diversion or other agreement, or it is deemed confidential or closed.

If YES to A or B, provide for each matter: (1) Name, mailing address, and telephone number of the regulatory agency; (2) Date; (3) Your license or bar number; (4) Case number, if applicable; (5) Detailed explanation of the allegations, circumstances, and outcome; and (6) provide a copy of all correspondence between you and the regulatory agency regarding the incident.

Name of Agency

Mailing Address

City

State/Province

Zip/Postal Code

Telephone Number

E-mail Address

License Date

Your license or bar number

Date of Incident

Case number

	Provide a detailed explanation

Unlicensed Law Practice

Have you ever been the subject of any formal or informal charges, complaints, or grievances (regardless of outcome) alleging that you engaged in the unauthorized practice of law, including any now pending?

If YES, provide for each matter: (1) Name, mailing address, and telephone number of the regulatory agency; (2) Date; (3) Case number, if applicable; (4) Detailed explanation of the allegations, circumstances, and outcome; and (5) provide a copy of all correspondences between you and the regulatory agency regarding the incident.

Name of agency

Mailing Address

City

State/Province

Zip/Postal Code

Telephone Number

Email Address

Date

Case Number

	Provide a detailed explanation

Sanctions

Have you ever been held in contempt of court, had sanctions entered against you, or otherwise been disqualified from participating in any case?

If YES, provide a copy of the petition and order of contempt, sanction, or disqualification for each occurrence and list the following: (1) Date; (2) Caption and case number of the case; (3) Name and address of the court; and (4) Detailed explanation of the reason(s) for the sanction or disqualification.

Date

Caption of case

Case Number

Name of the court

Mailing Address

City

State/Province

Zip/Postal Code

	Explanation

Other Licenses

Have you ever applied for a license (even if the application was withdrawn or denied) or held a license for a business, trade, occupation, or profession, other than as an attorney (e.g., CPA, real estate agent, physician, nurse, patent practitioner, etc.)?

If Yes, provide for each license: (1) Type of license; (2) Date of application; (3) Current status of license; (4) License number, if applicable; (5) Expiration/Inactive Date, if applicable; and (6) Name, mailing address, and telephone number of the licensing agency.

Type of license

Date of application

Current status of license

License number

Expiration/Inactive Date

Name of the licensing agency

Mailing Address

City

State/Province

Zip/Postal Code

Telephone Number

Email Address

Other Professional Discipline

14.A

As a holder of public office, or as a member of any profession other than law, including those you have/had a license for, have you ever been suspended, censured, reprimanded, disqualified, subject to discipline, or allowed to resign in lieu of discipline? Include matters where discipline was stayed or held in abeyance subject to a diversion or other agreement and include matters deemed confidential or closed.

14.B

As a holder of public office, or as a member of any profession other than law, including those you have/had a license for, have you ever been the subject of any formal or informal charges, complaints, or grievances concerning your conduct, including any now pending? Disclose all matters, even if the outcome was favorable, it was dismissed, no discipline was imposed, discipline was stayed or held in abeyance subject to a diversion or other agreement, or it is deemed confidential or closed.

If YES to A or B, provide for each matter: (1) Name, mailing address, and telephone number of the regulatory agency; (2) Date; (3) Your license number, if applicable; (4) Case number, if applicable; (5) Detailed explanation of the allegations, circumstances, and outcome; and (6) provide a copy of all correspondence between you and the regulatory agency regarding the discipline.

Name of the regulatory agency

Mailing Address

City

State/Province

Zip/Postal Code

Telephone Number

License Number

Case Number

	Provide a detailed explanation

Legal Proceedings

Noncriminal

In the past ten years, have you ever been a party to any noncriminal legal proceeding, including but not limited to any civil, administrative, family court, or domestic abuse proceeding, or any arbitration?

If Yes, complete a FORM 15 for each proceeding.

Business Entities

Has any business entity that you owned, managed, or participated in the control or management of been charged with fraud, larceny, embezzlement, misappropriation of funds, misrepresentation, or similar misconduct, in any civil, criminal, or administrative legal proceeding?

If Yes, complete a FORM 16 for each proceeding.

Commitment Proceedings

In the past ten years, have you been the subject of any proceeding for commitment based upon incompetency, mental health, or substance abuse?

If Yes, provide for each proceeding: (1) Name, mailing address, and telephone number of the court; (2) Date of proceeding; (3) Disposition; (4) Detailed explanation.

Name of the court

Mailing Address

City

State/Province

Zip/Postal Code

Telephone Number

Date of proceeding

Disposition

	Provide a detailed explanation

Violations of Law

In answering Questions 18, 19 and 20, you must disclose each instance even if charges were not brought against you or were dismissed, you were acquitted, you received a suspended imposition of sentence, the conviction was stayed or vacated, you were placed on probation, you were granted deferred adjudication, you participated in any type of pretrial diversion, or the record was sealed or expunged, and regardless of whether you have been advised by any source (including legal counsel) that you need not disclose the incident. No statute, court order or legal proceeding withholding adjudication, expunging or sealing any record, dismissing, vacating, or setting aside any arrest, charge, or conviction shall excuse less than full disclosure of the incident in this application.

18.A

Have you ever been issued a summons, cited, charged, taken into custody, or arrested for a felony, whether or not the charge was later reduced to a misdemeanor or other lesser charge?

If yes, add Form 18.A.

18.B

Have you ever been convicted of a felony?

If yes, add Form 18.B.

18.C

Have you served time in any correctional institution or work-release program?

If yes, add Form 18.C.

18.D

Have you served any part of a sentence of felony probation, regardless of adjudication of guilt? If yes, you must provide the board with a letter from the court of adjudication or the office of probation certifying to the termination date of the probation.

If Yes, add Form 18.D.

Have you ever been taken into custody, issued a summons, cited, charged, or arrested for driving under the influence (DUI), driving while intoxicated (DWI), driving with an unlawful blood alcohol level, minor in possession (MIP), public intoxication, or for any other alcohol or controlled substance related offense?

Have you ever been taken into custody, issued a summons, cited, charged or arrested for the violation of any law? (Exclude violations of traffic laws unless it resulted in time spent in jail or resulted in revocation or suspension of your driver's license. Exclude incidents included in Q. 19.)

If Yes to Q. 19 or 20, complete a FORM 19 for each incident and provide the police narrative report.

Court Ordered Evaluations

In the past five years, have you been required to undergo any court-ordered evaluation or treatment for the use or abuse of any substance including drugs or alcohol? (Include evaluations or treatment required in connection with any arrest for DWI, DUI, etc.)

If YES, provide for each evaluation or treatment: (1) Date(s); (2) Name, mailing address, and phone number of each person or facility conducting the evaluation or providing treatment; and (3) Detailed Explanation.

Date

Name

Mailing Address

City

State/Province

Zip/Postal Code

Telephone Number

	Provide a detailed explanation

Financial Responsibility

Surety On Bond

Has any surety on any bond on which you were a principal been required to pay any money on your behalf?

If Yes, provide for each instance: (1) Name, mailing address, and telephone number of the surety; (2) Amount of money paid by the surety; (3) Date money was paid; (4) Reason for the bond; and (5) Detailed explanation.

Name of surety

Mailing Address

City

State/Province

Zip/Postal Code

Telephone Number

Email Address

Amount paid

Date money was paid

Reason for the bond

	Provide a detailed explanation

Support Obligations

Have you ever been required to pay child support or maintenance obligations?

If YES, provide documentation verifying the status of each obligation.

Are you providing documentation verifying the status of each obligation?

	If NO, provide a detailed explanation of why you are not providing documentation verifying the status of each obligation, including your efforts to obtain a copy of said documentation and specifically to whom your requests have been directed and when.

Case Number, if applicable

Name of collecting agency or individual

Mailing Address

City

State/Province

Zip/Postal Code

Email Address

Phone number

Have you ever been past due at any time

Past due amount still due, if any

	Detailed explanation of circumstances surrounding past due obligation

Credit Accounts

In the past five years, have you been delinquent by more than 90 days in the payment of any credit account (student loans should be reported under Q25), had a credit card involuntarily revoked or canceled, a credit account involuntarily closed, or a debt referred to collection or “charged off” as not collectable?

If YES, provide documentation verifying the status, amount owed, and any repayment arrangements and list: (1) Name and mailing address of creditor; (2) Date account was opened and date account became past due; (3) Collection agency to which the debt was referred, if applicable; (4) Amount still owed; (5) Detailed circumstances leading to the default, delinquency, revocation, etc.; and (6) Circumstances preventing you from repaying on the default, delinquency, revocation, etc.

Name of the creditor

Account Number

Mailing Address

City

State/Province

Zip/Postal Code

Date Account Opened

Date Account became Past Due

Collection agency, if applicable

Amount owed

	Detailed circumstances leading to the default, delinquency, revocation etc.

	Detailed circumstances preventing you from paying on the default, delinquency, revocation, etc.

Student Loans

In the past five years, have you been delinquent by more than 90 days in the payment of any student loan account?

If YES, provide documentation verifying the status, amount owed, and any repayment arrangements and list: (1) Name and mailing address of creditor; (2) Date account was opened and date account became past due; (3) Collection agency to which the debt was referred, if applicable; (4) Amount still owed; (5) Detailed circumstances leading to the default, delinquency, etc.; and (6) Circumstances preventing you from repaying on the default, delinquency, etc.

Name of the creditor

Mailing Address

City

State/Province

Zip/Postal Code

Date Account Opened

Date Account became Past Due

Collection agency, if applicable

Amount owed

	Detailed circumstances leading to the default, delinquency, etc.

	Detailed circumstances preventing you from paying on the default, delinquency, etc.

Bankruptcy

In the past ten years, have you filed or been the subject of a petition in bankruptcy?

If YES, complete a Form 26 and provide a copy of filings in any adversary proceedings (if applicable), and the Docket Sheet.

Taxes

27.A

Have you ever failed to file any federal, state, or local tax return, when required by law?

If yes, add Form 27.A. for each incident.

27.B

Have you ever failed to timely pay any personal taxes due, including but not limited to any federal or state income taxes; state, county, or municipal private property taxes; or real estate assessment taxes?

If yes, add Form 27.B. for each incident.

27.C

Have you or any business or corporation or other entity in which you hold or held more than 20% equity interest or for which you served as an executive officer ever failed to pay or remit any business related taxes, including but not limited to, excise taxes, FICA taxes, income taxes, sales taxes, unemployment taxes, or withholding taxes?

If yes, add Form 27.C. for each incident.

Fitness

Preamble

Preamble to Questions 28, 29 and 30

Through this application, the Missouri Board of Law Examiners makes inquiry about circumstances that may affect an applicant's ability to meet the professional responsibilities of a lawyer. This information is treated confidentially by the Missouri Board of Law Examiners. The purpose of such inquiries is to allow the Missouri Board of Law Examiners to determine the current fitness of an applicant to practice law. The mere fact of treatment, monitoring, or participation in support group is not, in itself, a basis on which admission is denied; the Missouri Board of Law Examiners routinely certifies for admission individuals who demonstrate personal responsibility and maturity in dealing with fitness issues. The Missouri Board of Law Examiners encourages applicants who may benefit from assistance to seek it.

The Missouri Board of Law Examiners does, on occasion, deny certification to applicants whose ability to function is impaired in a manner relevant to the practice of law at the time that the licensing decision is made, or to applicants who demonstrate lack of candor by their responses. This is consistent with the public purpose that underlies the licensing responsibilities assigned to bar admission agencies; further the responsibility for demonstrating qualification to practice law is assigned to applicant pursuant Rule 8.13.

The Missouri Board of Law Examiners does not 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.

Fitness-1

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 or professional manner?

If yes, provide the relevant date(s) and a detailed explanation.

Relevant date(s)

	Provide a detailed explanation

Fitness-2

29.A

Do you currently have any condition or impairment (including, but not limited to, substance abuse, alcohol abuse, or mental, emotional, or nervous disorder or condition) that in any way affects your ability to practice law in a competent, ethical and professional manner?

29.B

If you answered "YES" to question 29.A., 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?

Dates of treatment

Name of treatment provider or hospital

Mailing Address

City

State/Province

Zip/Postal Code

	Describe the condition or problem

	Describe the treatment and/or monitoring program

Fitness-3

Within the past five years, have you asserted any condition or impairment as a defense, in mitigation, or as an explanation for your conduct in the course of 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?

If Yes, provide copies of all records relating to the proceeding, investigation, inquiry, or action and list the following for each instance: (1) Name, mailing address, and telephone number of the entity before which the issue was raised and (2) Detailed explanation.

Name of entity before which the issue was raised (i.e. court, agency, etc.)

Mailing Address

City

State/Province

Zip/Postal Code

Telephone Number

Relevant Date(s)

Disposition, if any

	Provide a Detailed Explanation

Character References

31	List three people who have known you well during the past five years. Do NOT list anyone who is listed elsewhere in this application, is a relative, a fellow law school student, employer, law partner or associate.

Name

Firm/Organization

Address

City

State/Province

Zip/Postal Code

Country

Daytime Telephone

Fax Number

E-Mail

Occupation

Attestation

I understand that this application is a continuing application and must state correctly and completely the information herein sought. No later than thirty (30) days after the happening of an event, I will update or amend this application to notify the Board of Law Examiners as to any change in any respect to any information provided or sought in this application or as to any incident which may have any bearing upon any information sought. I acknowledge that any false, misleading, evasive, or incomplete response in the foregoing application is inconsistent with the truthfulness and candor required of a practicing attorney and may be grounds for a finding that I lack the requisite character and fitness for admission to the bar in Missouri. I affirm under penalty of perjury that all statements contained in this application are true and complete.

I agree