San Gabriel Valley Bar

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					    ATTACHMENT #3


        Bankruptcy
          Business
          Criminal
      Estate Planning
        General/Civil
        Family Law
        Immigration
LaborlWrongful Termination
    Medical Malpractice
      Personal Injury
          Probate
       Social Security
  Workers Compensation
                       SAN GABRIEL VALLEY LAWYER REFERRAL SERVICE
                                1175 EAST GARVEY AVENUE #105
                               COVINA, CALIFORNIA 91724-3618
                           (626) 966-5530 . (626) 442-6973 . (909) 599-3847

                   BANKRUPTCY SUBJECT MATTER PANEL APPLICATION
                                   PLEASE TYPE

The undersigned attorney request that he/she be registered as a panelist for the Bankruptcy Panel.
This panel includes all bankruptcy questions, debtor, wage levies, and repossessions.

NAME

ADDRESS

PHONE                                     DATEADMITTEDTO THE BAR
An applicant who is currently certified by the California State Bar as a Bankruptcy Law Specialist
will automatically meet the experience requirements. Otherwise, applicant must certify experience
requirements as indicated below.
Mark which types of bankruptcy you qualify for:

0 Chapter 7:     Applicant must have filed and taken through discharge at least three Chapter 7
                 within the past three years.

 0 Chapter 11: Applicant must have represented at least two debtor in a Chapter 11 reorganization
               proceeding from filing of action to confirmation of plan, and have represented at
               least one creditor in a Chapter 11 reorganization proceeding from assertion of
               his /her claim to completion.

 0 Chapter 13: Applicant must have taken to confirmation of plan at least five Chapter 13
               "wage earner" plans within the past two years.

 0 Represented creditors in bankruptcy. Completed a total of 10 from the following categories:

                  1. . Adversary proceedings
                  2.   Objections to discharge
                  3.   Relief from stay
                  4.   Objections of plan or confirmation
                  5.   Major creditor or trustee matters

 1. What is your experience or other training in this field?




                                                  OVER
2. What library facilities do you personally have in this field:
      (a) CEB or other books
      (b) Periodicals & Services

3. What other criteria entitles you to be listed in this field?




The following is a description of the matters which I have handled:

                                          Court and                Description               Work
                  Case Name              File Number                of Matter              Performed

 1.


 2.


 3.


 4.


 5.

 I declare under penalty of perjury that the foregoing statements are true and correct.

 Dated this           day of                 , 20   at                      California.
 NOTE: Substantial Equivalent Experience: If you do not meet the stated requirements for panel
 membership, but believe that you qualify by reason of substantial, equivalent experience, you may
 submit an outline of such equivalent experience.




                                                                       Attorney' 5 Signature
                      SAN GABRIEL VALLEY LAWYER REFERRAL SERVICE
                               1175 EAST GARVEY AVENUE #105
                              COVINA, CALIFORNIA 91724-3618
                                            .                 .
                          (626)966-5530 (626) 442-6973 (909) 599-3847
                                         BUSINESS LAW
                               SUBJECT MATTER PANEL APPLICATION
                                          PLEASE TYPE

The undersigned attorney request that he/ she be registered as a panelist for the Business Law Panel.
This panel includes all matters having to do with formation of a business, non-profit organizations,
dissolution and buying and selling a business.

NAME

ADDRESS

PHONE                                              DATEADMITTEDTO THE BAR

QUALIFICATIONS: Applicant must have completed all legal work, including the preparation or
supervising the preparation of all legal documents, in not less than three client matters.

1. What is your experience or other training in this field?




2. What library facilities do you personally have in this field:
      (a) CEB or other books
      (b) Periodicals & Services

3. What other criteria entitles you to be listed in this field?




                                          Court and                Description           Work
                 Case Name               File Number                of Matter          Performed

 1.

                                                   OVER
                                        Court and               Description                Work
               Case Name               File Number               of Matter               Performed

2.

3.

I declare under penalty of perjury that the foregoing statements are true and correct.

Dated this         day of               , 20\~' at                    California.
NOTE: Substantial Equivalent Experience: If you do not meet the stated requirements for panel
membership, but believe that you qualify by reason of substantial, equivalent experience, you may
submit an outline of such equivalent experience.




                                                                    Attorney's Signature
                      SAN GABRIEL VALLEY LAWYER REFERRAL SERVICE
                               1175 EAST GARVEY AVENUE #105
                              COVINA, CALIFORNIA 91724-3618
                          (626) 966-5530. (626) 442-6973. (909) 599-3847

                                       CRIMINAL LAW
                             SUBJECT MATTER PANEL APPLICATION
                                        PLEASE TYPE

The undersigned attorney request that he/she be registered as a panelist for the Criminal Law Panel.
This panel includes all matters related to violation of criminal statutes or ordinances by any state,
local or federal governmental entity. This panel is divided into the Misdemeanor and Felony panels.
NAME
ADDRESS
PHONE                                               DATE ADMITTED TO THE BAR

An applicant who is currently certified by the California State Bar as a Criminal Law Specialist will
automatically meet the experience requirements. Otherwise, applicant must certify experience
requirements as indicated below.
Mark which types of criminal cases you qualify for:
D Misdemeanors: Attorney must have completed at least three criminal trials to judgment, at least
    one must be a jury trial; further, attorney must have handled no fewer than three criminal matters
    within one year.
D Felonies: Attorney must have completed all the above requirements for the state misdemeanors
    and have handled within three years, no fewer than three criminal matters, including: (a) one
    felony jury trial to judgment (b) one additional felony trial (c) three criminal pretrial motions
    involving either the submission of written points and authorities before the hearing or hearing at
    which witnesses were sworn and testimony taken.
1. What is your experience or other training in this field?




2. What library facilities do you personally have in this field:
    (a) CEB or other books

    (b) Periodicals & Services

 3. What other criteria entitles you to be listed in this field?




                                                   OVER
The following is a description of the matters which I have handled:

                                        Court and               Description                    Work
               Case Name               File Number               of Matter                   Performed

1.


2.


3.

I declare under penalty of perjury that the foregoing statements are true and correct.

Dated this          day of               , 20 'at                          California.
NOTE: Substantial Equivalent Experience: If you do not meet the stated requirements for panel
membership, but believe that you qualify by reason of substantial, equivalent experience, you may
submit an outline of such equivalent experience.




                                                                      Attorney's Signature
                                                  --   ---    -    -



                      SAN GABRIEL VALLEY LAWYER REFERRAL SERVICE
                               1175 EAST GARVEY AVENUE #105
                              COVINA, CALIFORNIA 91724-3618
                          (626) 966-5530. (626) 442-6973. (909) 599-3847

                                     ESTATE PLANNING
                             SUBJECT MATTER PANEL APPLICATION
                                        PLEASE TYPE
The undersigned attorney request that he/she be registered as a panelist for the Estate Planning
Panel. This panel includes all matters relating to wills, trust, gifts, estate tax and estate planning.
NAME
ADDRESS
PHONE .                                                DATE ADMITTED TO THE BAR

An applicant who is currently certified by the California State Bar as a Estate Planning Specialist will
automatically meet the experience requirements. Otherwise, applicant must certify experience
requirements as indicated below.
Mark which types of estate planning cases you qualify for:
0 Wills, Estate Planning: Drafting of at least 15 wills or a combination of wills, inter vivos trust
     agreements including at least one AB trust. Must have completed at least one educational pro-
     gram within the last 12 months.
0 Conservatorship, Guardianships or Mental Health Cases: Trial of at least one contested guardian-
     ship, or mental health case within the last two years or representation of parties in three uncon-
   --tested guardianship, conservatorship or mental health proceedings.
 0 Elderlaw: Must have handled three transactions concerning elderlaw.

1. What is your experience or other training in this field?




 2. What library facilities do you personally have in this field:
    (a) CEB or other books -
    (b) Periodicals & Services

 3. What other criteria entitles you to be listed in this field?




                                                       OVER
The following is a description of the matters which I have handled:

                                        Court and               Description                    Work
               Case Name               File Number               of Matter                   Performed

1.


2.


3.


4.


5.

I declare under penalty of perjury that the foregoing statements are true and correct.

Dated this         day of                ,20:   at                         California.
NOTE: Substantial Equivalent Experience: If you do not meet the stated requirements for panel
membership, but believe that you qualify by reason of substantial, equivalent experience, you may
submit an outline of such equivalent experience.




                                                                      Attorney's Signature
                      SAN GABRIEL VALLEY LAWYER REFERRAL SERVICE
                               1175 EAST GARVEY AVENUE #105
                              COVINA, CALIFORNIA 91724-3618
                          (626) 966-5530. (626) 442-6973. (909) 599-3847
                                       GENERAUCIVIL
                              SUBJECT MATTER PANEL APPLICATION
                                         PLEASE TYPE

The undersigned attorney request that he/she be registered as a panelist for the Civil Law Panel.
This panel includes all civil litigation matters excluding those covered by specific panels as set forth
herein.

NAME

ADDRESS

PHONE                                              DATE ADMITTED TO THE BAR

QUALIFICATIONS: Applicant must have handled three contested civil matters, including three
trials from filing of complaint, through discovery, to verdict or decision. Two arbitrations may substi-
tute for one bench trial. In addition, attorney must have handled three law and motion matters.

1. What is your experience or other training in this field?




2. What library facilities do you personally have in this field:
      (a) CEBor other books
      (b) Periodicals & Services

3. What other criteria entitles you to be listed in this field?



EXCLUDING:            0 Collections    0 Construction     0 Property Damage      0 Other

                                          Court and                Description               Work
                 Case Name               File Number                of Matter              Performed

 1.

                                                   OVER
                                        Court and               Description                   Work
               Case Name               File Number               of Matter                  Performed

2.


3.

I declare under penalty of perjury that the foregoing statements are true and correct.

Dated this         day of                , 2°. .at                        California.
NOTE: Substantial Equivalent Experience: If you do not meet the stated requirements for panel
membership, but believe that you qualify by reason of substantial, equivalent experience, you may
submit an outline of such equivalent experience.




                                                                     Attorney's Signature
                      SAN GABRIEL VALLEY LAWYER REFERRAL SERVICE
                               1175 EAST GARVEY AVENUE #105
                              COVINA, CALIFORNIA 91724-3618
                          (626) 966-5530. (626) 442-6973. (909) 599-3847

                                        FAMILY LAW
                             SUBJECT MATTER PANEL APPLICATION
                                        PLEASE TYPE

The undersigned attorney request that he/she be registered as a panelist for the Family Law Panel.
This panel includes pre or post-nuptial agreements, marital dissolutions, including adoptions, child
custody / support issues, marital settlement agreements and related domestic cases.

NAME

ADDRESS

PHONE                                               DATE ADMITTED TO THE BAR

An applicant who is currently certified by the California State Bar as a Family Law Specialist will
automatically meet the experience requirements. Otherwise, applicant must certify experience
requirements as indicated below.
QUALIFICATIONS: Applicant must have completed three marital dissolutions from filing of peti-
tion through final judgment, one of which must include Order to Show Cause hearings and child cus-
tody and visitation issues. For adoptions you must have completed one independent adoption from
filing petition to Decree.

1. What is your experience or other training in this field?




2. What library facilities do you personally have in this field:
    (a) CEB or other books
    (b) Periodicals & Services

 3. What other criteria entitles you to be listed in this field?




                                                   OVER




                                        ..-
                                        Court and               Description                  Work
               Case Name               File Number               of Matter                 Performed

1.


2.


3.

I declare under penalty of perjury that the foregoing statements are true and correct.

Dated this         day of                , 20' at                        California.
NOTE: Substantial Equivalent Experience: If you do not meet the stated requirements for panel
membership, but believe that you qualify by reason of substantial, equivalent experience, you may
submit an outline of such equivalent experience.




                                                                    Attorney's Signature
                      SAN GABRIEL VALLEY LAWYER REFERRAL SERVICE
                               1175 EAST GARVEY AVENUE #105
                              COVINA, CALIFORNIA 91724-3618
                          (626) 966-5530. (626) 442-6973. (909) 599-3847

                                       IMMIGRATION
                             SUBJECT MATTER PANEL APPLICATION
                                        PLEASE TYPE


The undersigned attorney request that he/ she be registered as a panelist for the Immigration Panel.
This panel includes all matters relating to labor certification, deportation, citizenship and visas.

NAME

ADDRESS

PHONE                                               DATEADMITTEDTO THE BAR

An applicant who is currently certified by the California State Bar as a Immigration Law Specialist
will automatically meet the experience requirements. Otherwise, applicant must certify experience
requirements as indicated below.

QUALIFICATIONS: Must have completed at least one educational program within the last 12
months.

1. What is your experience or other training in this field?




2. What library facilities do you personally have in this field:
    (a) CEB or other books
    (b) Periodicals & Services

 3. What other criteria entitles you to be listed in this field?




                                                   OVER
                                        Court and               Description                Work
               Case Name               File Number               of Matter               Performed

1.

2.


3.

I declare under penalty of perjury that the foregoing statements are true and correct.

Dated this         day of               ,201 ,at                      California.
NOTE: Substantial Equivalent Experience: If you do not meet the stated requirements for panel
membership, but believe that you qualify by reason of substantial, equivalent experience, you may
submit an outline of such equivalent experience.




                                                                    Attorney's Signature
                     SAN GABRIEL VALLEY LAWYER REFERRAL SERVICE
                              1175 EAST GARVEY AVENUE #105
                             COVINA, CALIFORNIA 91724-3618
                         (626) 966-5530. (626) 442-6973. (909) 599-3847
                            LABOR/WRONGFUL TERMINATION LAW
                            SUBJECT MATTER PANEL APPLICATION
                                       PLEASE TYPE

The undersigned attorney request that he/she be registered as a panelist for the Labor/Wrongful
Term~ation Panel. This panel includes all matters having to do with employment discrimination,
wrongful termination and all other Labor Law matters.

NAME

ADDRESS

PHONE                                             DATE ADMITTED TO THE BAR

Mark which types of labor /wrongful termination case you qualify for:

0 General Labor/Employment: Applicant must have been principal attorney of record in two gen-
  erallabor / employment actions within the last three years or attach a statement of experience per-
  taining to labor issue you have handled within the last five years.
0 Wrongful Termination: Applicant must have been principal attorney of record in at least three
  wrongful termination actions through settlement or trial within the last three years.
0 Employment Discrimination/Harassment: Applicant must have been principal attorney of record
  in at least three employment discrimination/harassment actions through settlement or trial with-
  in the last three years.
0 Employee benefits (Retirement, Pension, Cobra or ERISA): Applicant must have at least three
  years of experience in the employee benefits field and must have completed three units of contin-
  uing legal education pertaining specifically to employee benefits within the last three years.
0 Employer/Employee Union Disputes: Applicant must have represented clients in three matters
  involving a Federal or State Employee or Union Member through a contested hearing or settle-
  ment within the last three years.

 1. What is your experience or other training in this field?




 2. What library facilities do you personally have in this field:
    (a) CEB or other books
    (b) Periodicals & Services
                                                  OVER
3. What other criteria entitles you to be listed in this field?




                                          Court and               Description              Work
                Case Name                File Number               of Matter             Performed

1.


2.


3.

I declare under penalty of perjury that the foregoing statements are true and correct.

Dated this         day of               , 20 at                       California.
NOTE: Substantial Equivalent Experience: If you do not meet the stated requirements for panel
membership, but believe that you qualify by reason of substantial, equivalent experience, you may
submit an outline of such equivalent experience.




                                                                     Attorney's Signature
- - --

                          SAN GABRIEL VALLEY LAWYER REFERRAL SERVICE
                                   1175 EAST GARVEY AVENUE #105
                                  COVINA, CALIFORNIA 91724-3618
                              (626) 966-5530. (626) 442-6973 . (909) 599-3847

                  MEDICAL MALPRACTICE SUBJECT MATTER PANEL APPLICATION
                                      PLEASE TYPE

   The undersigned attorney request that he/she be registered as a panelist for the Medical Malpractice
   Panel. This panel includes all matters relating to tort claims against persons or entities involved in
   the medical care of a client.

   NAME
   ADDRESS
   PHONE                                               DATEADMITTEDTO THE BAR
   QUALIFICATIONS: Applicant must have prepared and tried three medical malpractice cases to ver-
   dict, or two medical malpractice cases to verdict and any combination of two judicial arbitrations or
   court trials to judgment, or one medical malpractice case to verdict and any combination of four judi-
   cial arbitrations or court trials to judgement.                                  .   .



    1. What is your experience or'.other trainiHg in this field?
                                           "




    2. What library facilities d~you personally have in this field:
                              .   .'   "


          (a) CEBor other books'-:'"
          (b) Periodicals & Services

    3. What other criteria entitles you to be listed in this field?




    The following is a description of the matters which I have handled:

                                                Court and             Description             Work
                     Case Name                 File Number             of Matter            Performed

     1.


     2.


                                                       OVER
                                     Court and              Description             Work
              Case Name             File Number              of Matter            Performed

3.

4.


5.

I declare under penalty of perjury that the foregoing statements are true and correct. Dated this
day of-    , 20. at                            , California.
NOTE: Substantial Equivalent Experience: If you do not meet the stated requirements for panel
membership, but believe that you qualify by reason of substantial, equivalent experience, you may
submit an outline of such equivalent experience.

                                                               Attorney's Signature
                        SAN GABRIEL VALLEY LAWYER REFERRAL SERVICE
                                 1175 EAST GARVEY AVENUE #105
                                COVINA, CALIFORNIA 91724-3618
                            (626) 966-5530. (626) 442-6973. (909) 599-3847

                         PERSONAL INJURY SUBJECT PANEL APPLICATION
                                        PLEASE TYPE

The undersigned attorney request that he/she be registered as a panelist for the Personal Injury
Panel. This panel includes all matters relating to tort claims against persons or entities including per-
sonal injury claims, property damage, wrongful death cases, intentional tort and defamation cases.
NAME
ADDRESS
                                                          "f:   ;..,~~
PHONE                                                DATE ADMITTED TO THE BAR
                                                        <  _,-f.



QUALIFICATIONS: Applicant must have settled te~ personal injury cases, at least five that have
gone to trial or through arbitration within the last five years (defendant or plaintiff.

1. What is your experience or other training in this field?




2. What library facilities do you personally have in this field:
      (a) CEB or other books

      (b) Periodicals & Services

3. I certify that in the last_years      I have handled personal injury matters or cases that have either:
      (a) Have handled at least ten personal injury cases or;
      (b) handled at least five cases that have gone to trial or through arbitration.
List five (5) personal injury matters or cases you have handled:
                                            Court and                    Description          Work
                  Case Name                File Number                    of Matter         Performed

 1.


 2.


 3.


                                                     OVER
                                      Court and               Description               Work
              Case Name              File Number               of Matter              Performed

4.

5.

I declare under penalty of perjury that the foregoing statements    are true and correct. Dated this

day of -    , 201 . at                        , California.
NOTE: Substantial Equivalent Experience: If you do not meet the stated requirements for panel
membership, but believe that you qualify by reason of substantial, equivalent experience, you may
submit an outline of such equivalent experience.

                                                                   Attorney's SIgnature
                                                ---           --   -----

  - ----


                            SAN GABRIEL VALLEY LAWYER REFERRAL SERVICE
                                     1175 EAST GARVEY AVENUE #105
                                    COVIN A, CALIFORNIA 91724-3618
                                (626) 966-5530. (626) 442-6973. (909) 599-3847
                             PROBATE SUBJECT MATTER PANEL APPLICATION
                                            PLEASE TYPE
The undersigned          attorney request that he/ she be registered as a panelist for the Probate Panels.
NAME
ADDRESS
PHONE                                                        DATE ADWTTED TO THE BAR
An applicant who is currently certified by the California State Bar as a Probate Law Specialist will
automatically meet the experience requirements. Otherwise, applicant must certify experience
requirements as indicated below.
I have (a) handled at least five completed probate administrations in the last five years (b) prepared
and processed at least one accounting in connection with a probate of a will or an interstate's estate
administration and (c) handled at least two from the following:
    1. The Contest of a Will
           2. Petition to Determine Heirship
           3. Petition for Instructions
           4. A Trust Termination
           5. A Joint Tenancy Termination
           6. Preparation and Filing of the IRS Form 706
            7. Preparation and Filing of a 13100Petition
            8. Petition for Widow's Allowance
            9. Petition for return of sale and real property
           10. Assisted in transfer of assets pursuant to a living trust
   The following is a description of the matters which I have handled:
                                                       Court and           Description                Work
                         Case Name                    File Number           of Matter               Performed

    1.

    2.

     3.

     4.

      5.



                                                                   OVER
1 ut=uare unaer penalty or pel"Jury that the toregoing statements are true and correct.

Dated this          day of                ,20   ,at                        California.
NOTE: Substantial Equivalent Experience: If you do not meet the stated requirements for panel
membership, but believe that you qualify by reason of substantial, equivalent experience, you may
submit an outline of such equivalent experience. .




                                                                      Attorney's Signature.
                       SAN GABRIEL VALLEY LAWYER REFERRAL SERVICE
                                1175 EAST GARVEY AVENUE #105
                               COVINA, CALIFORNIA 91724-3618
                           (626) 966-5530. (626) 442-6973. (909) 599-3847
                                        SOCIAL SECURITY
                               SUBJECT MATTER PANEL APPLICATION
                                          PLEASE TYPE

The undersigned attorney request that he/ she be registered as a panelist for the Social Security Panel.
This panel includes all matters relating to social security appeals.

NAME

ADDRESS

PHONE                                              DATE ADMITTED TO THE BAR

QUALIFICATIONS: Applicant must have handled, within the last three years, not fewer than three
social security appeals through final resolution.

1. What is your experience or other training in this field?




2. What library facilities do you personally have in this field:
      (a) CEB or other books
      (b) Periodicals & Services

3. What other criteria entitles you to be listed in this field?




 The following is a description of the matters which I have handled:

                                          Court and                Description              Work
                 Case Name               File Number                of Matter             Performed

 1.

                                                   OVER
                                        Court and               Description                Work
               Case Name               File Number               of Matter               Performed

2.

3.

I declare under penalty of perjury that the foregoing statements are true and correct.

Dated this         day of                , 20:~' at                      California.
NOTE: Substantial Equivalent Experience: If you do not meet the stated requirements for panel
membership, but believe that you qualify by reason of substantial, equivalent experience, you may
submit an outline of such equivalent experience.




                                                                    Attorney's Signature
-

                          SAN GABRIEL VALLEY LAWYER REFERRAL SERVICE
                                   1175 EAST GARVEY AVENUE #105
                                  COVINA, CALIFORNIA 91724-3618
                              (626) 966-5530. (626) 442-6973. (909) 599-3847

               WORKERS COMPENSATION               SUBJECT MATTER PANEL APPLICATION
                                                 PLEASE TYPE


    The undersigned       attorney request that he/ she be registered as a panelist for the Workers
    Compensation Panel. This panel includes all matters relating to the prosecution of claimant's claims
    for industrial injuries from on-the-job accidents.

    NAME

    ADDRESS

    PHONE                                              DATE ADMITTED TO THE BAR

    An applicant who is currently certified by the California State Bar as a Worker's Compensation
    Specialist will automatically meet the experience requirements. Otherwise, applicant must certify
    experience requirements as indicated below.

    QUALIFICATIONS: Applicant must have handled at least five workers compensation cases within
    the past three years involving different claimants from application through the findings and awards,
    or compromise and release.
    1. What is your experience or other training in this field?




    2. What library facilities do you personally have in this field:
        (a) CEB or other books

        (b) Periodicals & Services

    3. What other criteria entitles you to be listed in this field?




                                                      OVER
The following is a description of the matters which I have handled:                           \

                                        Court and                Description
                                                                                              \
                                                                                           WorK
               Case Name               File Number                'ofMatter              Performed

1.


2.


3.


4.

I declare under penalty of perjury that the foregoing statements are true and correct. Dated this
day of-      , 20\ ' at                          , California.
NOTE: Substantial ~quivaJ,~~~ExpeQence: If you do not meet the stated r~quirements for panel
membership, but believe that you qualify by reason of substantial, equivalent experience, you may
submit an outline of such equivalent experience.



                                                                      Attorney's Signature