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APPLICATION FORMUNITED STATESBANKRUPTCY ADMINISTRATORFull Name:Present Office Address:Present Office Telephone Number (with area code):Residential Address:Residential Telephone Number (with area code):Place of Birth:Are you related to any United States District or Circuit Judge?YesNoIf yes, please list name(s), office address, and telephone number (with area code).NameOffice AddressTelephone NumberHave you had any military service?YesNoIf yes, give dates, branch of service, rank, serial number, and present status. If discharged, state character ofdischarge.Dates of ServiceBranchRankSerial NumberStatusList each college and law school you attended, including dates of attendance, the degrees awarded, and, if youleft any institution without receiving a degree, the reason for leaving.School NameDates of AttendanceDegree(s)Reason for Leaving1
List any major academic achievements and other significant activities in college:List any major academic achievements and other activities in law school (e.g., Coif, Law Review, Moot Court,etc.):List all courts to which you have been admitted to practice with dates of admission. Give the same informationfor administrative bodies which require special admission to practice:Court/Administrative BodyDate of AdmissionDescribe chronologically your legal and other experience including:(a) Whether you served as law clerk to a judge, and if so, the name of the judge, the court, and the datesof the period you were a clerk:JudgeCourtClerkship Dates2
(b)Whether you practiced law alone, and if so, the addresses and dates:YesNoOffice AddressDates of Practice(c) The dates, names and addresses of law firms or offices, companies, governmental agencies, or otherorganizations with which you have been connected, and the nature of your connection with each:Firm, Agency, orAddressDates ofNature ofOrganization NameEmployment orConnectionAssociation(d) Law teaching experience, including name of law school, dates, courses, and faculty rank:Law SchoolCourses TaughtDates of ServiceFaculty RankIf you have practiced law, what was or has been the general character of your practice, dividing it into periodswith dates if its character has changed over the years:Character of PracticeTime Period3
Describe your typical clients, or former clients, and mention the areas, if any, in which you have specialized:Have you ever been convicted by a federal, state, or other court for violation of any federal law or regulation,state law or regulation, county or municipal law, regulation, or ordinance?YesNoIf so, provide details. Do not include traffic violations for which a fine of 50.00 or less was imposed.Has a tax lien or other collection procedure ever been instituted against you by federal, state, or localauthorities?YesNoIf so, describe the particulars:4
Have you ever been disciplined or cited for a breach of ethics or unprofessional conduct by any court,administrative agency, bar association, disciplinary committee, or other professional group?YesNoIf so, provide details:List your previous experience working in the administration of decedents’ estates, debtors’ estates, or similartype work:Describe in detail the work you have performed in the administration of estates or similar type work whichserves to qualify you for the position of Bankruptcy Administrator:5
What experience do you have in evaluating professionals for employment, supervising professionals in theperformance of administrative or legal duties, and in managing an office with significant administrative andlegal responsibilities?What experience do you have in preparing, reviewing, and comprehending profit and loss statements, balancesheets, financial statements, and other documents used in the operation and management of a business?6
What other special background or experience do you possess that serves to qualify you for supervising trusteesin the administration of debtors’ estates and supervising the administration of debtors’ estates under thebankruptcy law?State the names, addresses, and telephone numbers of three persons who are well acquainted with your legalability and personal character:NamePhoneAddressState any other pertinent information reflecting positively or adversely on you which you believe should bedisclosed in connection with your possible appointment as a United States Bankruptcy Administrator:7
Certification of ApplicationI declare under penalty or perjury that the foregoing is true and correct.DateSignature of Candidate8
7 . What other special background or experience do you possess that serves to qualify you for supervising trustees in the administration of debtors' estates and supervising the administration of debtors' estates under the
