APPELLATE COURT APPOINTMENT Pg. 2

1. Name of Applicant:

Prefix:

First Name:

Middle Name:

Last Name:

Suffix:

2. Prior names used by Applicant (Include the dates each name was used.):

3. Preferred Judicial Position (in the space requesting "division" preference, please type the word "ANY", unless you are applying for the Second District Court of Appeal, Division 6; or you are applying for any of the divisions of the Fourth District Court of Appeal, in which case you should indicate which division you are applying for):

Justice of the:

- Division:

4. Business/Government Information:

Business/Government Title:

Firm/Office:

Address:

City:

County:

State:

Zip:

Phone:

Ex:(###)###-####

Email:

5. Date of Birth:

Place of Birth:

Drivers License #:

Social Security #:

Ex:###-##-####

California Bar #:

Admission Date:

Please indicate whether you meet the mandatory eligibility requirement to serve as a judge on a California court. ("A person is ineligible to be a judge of a court of record unless for 10 years immediately preceding selection, the person has been a member of the State Bar or served as a judge of a court of record in this State." (Cal. Const, Art. VI)):

If you meet the eligibility requirement for judicial service, please answer the remaining questions set forth in this questionnaire.

INFORMATION FOR REPORTING PURPOSES

6. State law requires the Governor's Office to collect, on an aggregate statewide basis, demographic data relative to ethnicity, race, disability, veteran status, gender, gender identity and sexual orientation (Gov. Code, §12011.5, subdivision (n)). To assist the Governor's Office with these reporting obligations, applicants are asked to voluntarily provide the information below. YOUR ANSWERS TO THESE QUESTIONS ARE PURELY VOLUNTARY AND YOU MAY FREELY SKIP ANY OR ALL OF THESE QUESTIONS AND GO DIRECTLY TO QUESTION 7. If you choose to respond, use the categories below to choose the one(s) with which you most closely identify.

Please identify your gender:

Please state your Ethnicity:

Please identify your sexual orientation/gender identity:

Please identify if you are a veteran as that term is defined in Section 101(2) of Title 38 of the United States Code:

Please identify if you are person with a mental or physical disability as that term is defined in subdivisions (j), (l), and (m) of California Government Code Section 12926:

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