Georgia Office Of Bar Admissions -

Character & Fitness Questionnaire

PREAMBLE

If you have questions about the Fitness Application, you should first consult the following:

- Policy Statement of the Fitness Board Regarding Character and Fitness Reviews

- Civility Policy

- Making the Mark; Character and Fitness for Admission to the Bar

- Frequently Asked Questions

I understand that the above documents are available to answer questions about the Fitness Application.

PERSONAL INFORMATION

Personal Information

Please enter your personal information.

All processing will be done on the basis of your full legal name; therefore, all records will be maintained and certification(s) issued in your full legal name.

Full legal name

By what name are you usually called?

Date of birth

Birth City

Birth State

Birth Country

Contact Information

CONTACT INFORMATION
You are responsible for updating your contact information whenever it changes, up until the time you receive a Certificate of Eligibility to Practice Law. You can update your contact information by clicking on "Edit Personal Info" above.

Email Address

Street or P.O. Box #

Apt. # or Address 2

City

State

ZIP Code

Cell Phone

Other Phone

Other First, Middle, or Last Name

Have you ever been known by another name other than a nickname (e.g., a maiden name)?

List each name used or by which you have at any time been known, and the dates that name was used.

If your name was changed by court order, upload a copy of the court order or documentation evidencing your legal name change.

Last Name (Maiden)

First Name

Middle Name

From Mo/Yr

To Mo/Yr

	Reason name was used

Social Security Number

Have you ever been issued or used any social security number other than the one you provided when you created an account with the Office of Bar Admissions, or have you ever been issued a similar number in another country?

Provide the social security number(s) you have used and explain the reason why you have had more than one number.

Social Security Number

	Explanation

Law School

Please choose the name of the law school that conferred or will confer your degree. If your law school is not listed, please contact the Office of Bar Admissions.

Citizenship Information

1.1

Were you born in the United States?

You must upload a copy of your birth certificate or U.S. Passport. You will be able to upload documents to your file after you file your fitness application. You will use the "Upload New Document" button at the bottom of your homepage.

1.2

Were you born in a foreign country to US citizen parents?

You must upload a copy of the Consular Certificate of Birth Abroad.

1.3

Are you a naturalized United States citizen?

1.4

Do you reside lawfully in the United States as a Permanent Resident?

1.5

Do you currently hold the F-1 student Visa?

You must print, complete, and submit the Nonimmigrant Affidavit, along with your Fitness Application, and provide the required documentation to support the claims made in the Affidavit.

1.6

Have you recently filed an application with United States Citizenship and Immigration Services (USCIS) to adjust your status to that of a Permanent Resident of the United States?

Upload a copy of the Notice of Action form issued by the USCIS and provide a copy of the citizenship page of your passport.

If you are not a citizen of the United States or if you are not a Permanent Resident of the United States, you must print, complete, and submit the Nonimmigrant Affidavit, along with your Fitness Application, and provide the required documentation to support the claims made in the Affidavit.

Upload a copy of the front and back of your Permanent Resident Card.

Upload a copy of your Certificate of Naturalization or Certificate of Citizenship.

Selective Service

Male citizens and permanent residents who are under 26 years old must be registered with the Selective Service System.

You can verify your registration at: https://www.sss.gov/verify.

2.1

Have you registered with Selective Service?

Selective Service Number

Please contact the Selective Service at 847-688-6888 or by visiting the above website.

Please explain

	Please explain

Marital Status

3.1

Are you married?

3.2

Enter the full legal name of your spouse.

Date of Marriage

3.3

Have you ever been widowed, been divorced, or had a marriage annulled or set aside?

If a marriage was terminated by court order, you must upload copies of the following documents relating to each divorce: the complaint, response, and final decree.

Please select

3.4	Provide the name of your former spouse and state when, where, and how your marriage was terminated. If you are widowed, please provide the name of your deceased spouse.

4.1

Have you ever been under court ordered obligation to pay alimony or child support?

4.2

State your compliance with such support payments and list the name and last known address of your former spouse(s) or the custodial parent of your child(ren) to whom support is or was to be paid. Please also upload a copy of the court order unless it is already provided by the requirements of the previous question.

Name of Former Spouse/Custodial Parent of Your Child(ren)

	Number of Children

Address 1

Address 2

City

State

ZIP Code

Email Address

	State your compliance with support payments.

OTHER JURISDICTIONS

Other Jurisdictions

5.1

Have you ever submitted a character and fitness application (or a bar exam application that includes fitness questions) for admission to the Bar of any United States jurisdiction (including Georgia)?

5.2	In what state(s) have you applied for admission and when?

You must upload a complete copy of each such application other than Georgia. If not available, you must upload a letter from the jurisdiction stating that the application is not available.

Name of Jurisdiction

Date Applied

Informal Interview or Formal Hearing

5.3

Have you ever, other than as a routine practice, had your fitness to practice law questioned through an informal interview, a formal hearing, or by any other means?

	Explain for each instance (of questioning, interview, or hearing) including the reason(s) for the questioning, the nature of the questioning, and the outcome. Upload any correspondence or documentation regarding the questioning, interview, or hearing.

Bar Examination

6.1

Have you ever taken the bar examination in any United States jurisdiction (including Georgia)?

6.2	If yes, provide the following information.

Jurisdiction

Date of Examination

Pass, fail, or awaiting result

Denied Admission to the Practice of Law

7.1

Have you ever been denied admission to the practice of law in any jurisdiction, other than for failure of the bar examination, or been denied permission to take the bar examination of any jurisdiction?

	Explain the denial of admission, including the name of the denying jurisdiction, the date of the denial, and the reason why you were denied. Upload documentation related to the denial of admission.

Admission to the Practice of Law

8.1

Have you ever been admitted to the practice of law in any United States jurisdiction, including Georgia?

8.2

Indicate in which jurisdiction(s) you have been admitted, the date of admission, and whether it was by Examination or by Motion, and include your State Bar Membership Number. Be sure to include ALL of the jurisdictions in which you have ever been admitted, even if you never practiced law in the jurisdiction.

You must upload a disciplinary history letter for each state where you have been admitted and a letter of good standing and disciplinary letter for each jurisdiction in which you are currently admitted. Not all states issue both documents; therefore, please check with the jurisdictions in which you are admitted to determine what will be required.

Name of jurisdiction

Admission Date

Type of application

State Bar Membership Number

Good standing

8.3

Are you in good standing in every jurisdiction in which you are admitted and were you in good standing at the time you ceased being admitted in any other jurisdiction?

8.4	Indicate which jurisdiction(s) and explain why you are not in good standing.

State

	Explanation

Complaints

8.5

Have any complaints or charges been filed against you as an attorney with the disciplinary authority of any jurisdiction in which you have been admitted to practice?

For each instance in which such a complaint or charge was filed, state the name of the agency, authority, board, or committee to whom the complaint was addressed; the date of the complaint; the nature of the complaint, and the disposition of the complaint.

You must upload copies of all documents and correspondence in each matter.

Name of Agency

Date of the complaint

Action/File/Case Number

	Nature of complaint

	Disposition

	Other information

Discipline

8.6

Have you been the subject of any disciplinary action or pre-disciplinary agreement, whether private or public, whether oral or written, in any jurisdiction in which you are or have been admitted to the practice of law?

Provide, for each instance of discipline, the name of the jurisdiction imposing the discipline, the facts and circumstances leading to the discipline, the date of the discipline, the nature of the discipline, the nature of the offense for which the discipline was imposed, and any other information you deem appropriate. Upload documentation regarding the discipline.

Name of jurisdiction

Date of the discipline

Action/File/Case Number

	Nature of the discipline

	Nature of the offense

	Other information

	Facts and Circumstances

8.7

Have sanctions by a court ever been entered against you (including contempt), or have you ever been disqualified from participating in any case?

	Explain the sanction or disqualification, including the name of the court, date, and the reason for the sanction or disqualification. Upload a copy of the order of sanction or disqualification.

RESIDENTIAL HISTORY

Permanent and Temporary Addresses

9.1	Beginning with your current residence, list every place you have resided for more than three months in the last five years (or since your 18th birthday). If you resided on a school campus, you only need to list the name and address of the school.

NOTE: Adding an address on this screen DOES NOT update your current mailing address. To update your current mailing address, click on "Edit Personal Info" at the top of your homepage.

Resided From

Resided Until

Address Line 1

Address Line 2

City

State or Province

ZIP Code

Country

EDUCATIONAL INFORMATION

College (Excluding Law School)

10.1	Provide the following information for each college and university you have attended (other than law school) for more than five months.

College Name

Address 1

Address 2

City

State or Province

ZIP Code

Country

Dean of Students' Email

Attended From

Attended To

Name of Degree Conferred

	Additional Information

Law School

11.1	Provide the following information for each law school you are presently attending as well as each law school you previously attended.

University Name

School Name

Address 1

Address 2

City

State or Province

ZIP Code

Dean of Students' or Registrar's Email

Attended From

Attended To

Name of Degree Conferred or Expected to be Conferred

	Additional Information

Educational Disciplinary

12.1

Have you ever been dropped, suspended, dismissed, warned, placed on scholastic or disciplinary probation, expelled, or requested to resign from any college, university, or law school or otherwise subjected to written discipline by any such institution or requested or advised by any such institution to discontinue your studies?

List each occurrence and list the date and circumstance of the occurrence(s).

College/University

Date of Occurrence

	Circumstance of Occurrence

12.2

Have you ever been formally charged with cheating, dishonesty, or otherwise taking unfair advantage of fellow students at any college, university, or law school you attended or are presently attending?

Provide complete details of each instance, its disposition, and the punishment imposed, if any.

College/University

	Disposition

	Punishment imposed

	Details of instance

12.3

Regardless of whether the record has been expunged, cancelled, or annulled, and whether no record was made, have you ever been subject to proceedings before a school honor court or council (or any similar body)?

Provide a narrative for each instance including the date, full details of such charges, disposition, and the punishment imposed, if any. Upload a copy of any documentation or correspondence between you and the institution.

College/University

Date of instance

	Details of charges

	Disposition

	Punishment imposed

MILITARY SERVICE

Armed Forces

13.1

Are you now or have you ever been a member of the armed forces of the United States, including the National Guard, or any of the reserve components?

Upload a Report of Separation, Form DD214, or its equivalent for each period of active duty.

Dates of periods of active duty:

Start Date

End Date

Branch of Service

Highest Rank Achieved

Date of Discharge

Type of Discharge

If you are currently active in a reserve unit, provide the mailing address of your reserve unit.

I am currently in an active reserve unit.

Address 1

Address 2

City

State

ZIP Code

Country

13.4

As a member of the armed forces, were court martial charges ever made or proceedings instituted against you?

State the date, the nature of the charges, the facts, the disposition of the matter, and the location and designation of the military establishment where such proceedings took place.

Date

	Nature of the charges

	Facts

	Disposition of the matter

Location of the military establishment

13.5

As a member of the armed forces, was non-judicial punishment imposed upon you?

For each imposition of non-judicial punishment, provide the date, the nature of the offense, the facts surrounding its occurrence and the location and designation of the military unit or command imposing punishment.

Date of imposition

	Nature of the offense

	Facts

	Location of the military unit

13.6

As a member of the armed forces, were you asked to resign or given the opportunity to resign in lieu of judicial or administrative proceedings being instituted or carried out against you?

Give the date of such resignation, the nature of the proceeding that was or would have been instituted against you, and the designation of the military unit or command that instituted or would have instituted proceedings against you.

Date of resignation

	Nature of the proceedings

	Designation of the military unit

EMPLOYMENT

Notification

EMPLOYMENT
On the next page, you will be asked to provide your employment history. You should include all employment, including both law-related and non-law-related positions. We will contact your present and past employers, so please take care to provide the most current contact information available.

Employment History

Provide a complete list of your employment, beginning with your current or most recent employment and going back 10 years or to your 18th birthday (whichever is less). You do not need to disclose isolated or "odd job" employment, such as babysitting, tutoring, or yard work, in which you were employed by an individual at their home for less than 10 hours per week.

In addition, you should list ALL law-related employment, even if that employment was more than 10 years ago. If a law-related position was with a firm that has changed or been dissolved, please provide the name and contact information of a supervisor who previously worked at that firm and can verify your employment. You should not list a third party vendor (or verification service) as a contact for law-related employment.

14.1

Have you ever been employed or had an internship or externship?

Employer Name

Is this Position Law Related?

Supervisor Name or Employment Verification Contact

Your Position

Please indicate whether this position was paid, volunteer, or for academic credit.

Are you currently employed at this job?

	Reason for Leaving

Month/Year Started

Month/Year Ended

Email Address of Supervisor or Employment Verification Contact

An email address is strongly preferred and will allow us to process your application more efficiently. If this is a legal employer, it is highly likely that you can provide an email address. Make sure that you provide a valid domain and that you have not added any spacing or punctuation at the end of the domain name. If you are unable to provide an email address at this time, you may type "unknown" to proceed with your application. You can amend your application after it is submitted with valid email addresses.

Address 1

Address 2

City

State

ZIP Code

Country

	Additional Information

During all time periods since my 18th birthday (or within the last ten years) not covered in my answer above, I was unemployed or attending school.

Discharge

14.2

Have you ever been discharged from any employment?

For each instance, provide the date and circumstances. If the employer was not an individual, provide the name and title of the supervisor.

Date

	Circumstances

Name of Employer

Address 1

Address 2

City

State

ZIP Code

Name of Supervisor

Email address of supervisor or employment verification contact

Discipline

14.3

Have you ever been disciplined by an employer, or requested, formally or informally, to resign from or terminate employment?

For each instance, provide the date, circumstances, and the name and address for each employer. If the employer was not an individual, provide the name and title of the person providing such discipline or making such a request.

Date

	Circumstances

Name of Employer

Address 1

Address 2

City

State

ZIP Code

Country

Name of Supervisor

Email address of supervisor or employment verification contact

CREDIT

Credit Information

15.1

Do you have, or have you had during the last five years, a credit account with any merchant, bank, mortgage company, any other financial institution, credit union, or any other business or credit enterprise?

Provide information on all lines of credit, credit cards, and credit accounts, whether used or not and whether now active or not. Include accounts with zero balances. Be sure to include mortgages, car leases, car loans, joint accounts, and accounts on which you are an authorized user. Include information on all accounts for the last 5 years.

DO NOT ENTER STUDENT LOANS IN THIS SECTION; THAT INFORMATION IS LISTED ELSEWHERE.

DO NOT SEND A COPY OF YOUR CREDIT REPORT IN LIEU OF COMPLETING THIS QUESTION.

For purposes of updating, please note: You are required to amend all changes with regard to credit except changes in monthly credit balances.

15.2	Credit Accounts Information

Creditor

Account Type

Approximate Balance Currently Owed (do not include "$")

Collection Agency

15.3

In the last seven years, have you ever had any type of account or debt turned over to a collection agency or an account that has been charged off?

Provide the name and address of the creditor, account number, and current balance, and describe the steps you have taken to satisfy the debt. If the account is paid in full, you must upload demonstrable proof. Remember that the "Upload New Document" button will appear at the bottom of your homepage after you file your fitness application, and you will use that feature to upload documentation related to the collections/charge offs and/or letter from the creditor.

Name of Creditor

Address 1

Address 2

City

State

ZIP Code

Country

Account Number

Current Balance

	Describe the steps you have taken to satisfy the debt.

Creditor Judgment

15.4

Has a judgment ever been entered against you in favor of a creditor or any other entity?

Name of Holders

Address 1

Address 2

City

State

ZIP Code

Country

	Additional Information

List the names and present mailing addresses of the holders and furnish copies of such judgments.

If satisfied, you should upload a copy of the satisfaction of judgment.

If not satisfied, you should upload a statement concerning the current status of the judgment, including copies of any correspondence concerning payment of the judgment.

Liens or Garnishments

15.5

Have you ever had any liens or garnishments filed against you?

If your answer to this question is "Yes," you must read the Policy Statement of the Board to Determine Fitness of Bar Applicants Regarding Character and Fitness Reviews, which you can find here. You should pay special attention to Section D. If applicable, upload a copy of all correspondence, updates, and documentation regarding any outstanding IRS lien.

Provide the names and addresses of the holders; the amounts of the liens or garnishments; and, if satisfied, upload certified copies of the satisfactions.

Name of Holder

Address 1

Address 2

City

State

ZIP Code

Country

Amount of Lien

Amount of Garnishment

	Additional Information

Bankruptcy

15.6

Have you ever filed a petition in bankruptcy or for establishment of a wage earners plan?

For each filing, list the court in which such petition was filed, the date of filing, and the final disposition of the matter. You must upload a copy of the petition, list of creditors, and the order of discharge.

Type of Bankruptcy

Name of Court

Date of Filing

Case Number

	Final Disposition

	Reason for Bankruptcy

	Additional Information

STUDENT LOANS

Student Loan

For student loans that were satisfied over ten years ago and do not appear on your credit report, select "No."

16.1

Have you ever obtained a student loan?

16.2

Are your student loans in deferment or forbearance?

If so, upload related documentation.

16.3

Total amount of student loans owed

16.4

Have you ever defaulted on a student loan?

It is recommended that you pull a current credit report to verify the status of any loans.

You must provide complete mailing addresses including ZIP codes.

Loan Holder

Address 1

Address 2

City

State

ZIP Code

Country

Account Number

Original Loan Amount

Amount Currently Owed

	Explanation of Default

Defaulted on a Student Loan

16.5

Have you ever defaulted on a student loan? You must answer even if the debt is now satisfied.

Provide the name and address of the creditor, the loan account number, the amount owed and, if still in default, what steps have been taken to bring the account up-to-date.

Upload current documentation from your lender or servicer showing the status of each defaulted student loan.

Guarantor/Lender

Address 1

Address 2

City

State

ZIP Code

Account Number

Default Amount

Amount Currently Owed

Date Defaulted

	State the steps you have taken to bring the account up-to-date.

Student Loan Judgment

16.6

Has a judgment ever been entered against you in favor of a student loan guarantor or lender?

Provide the names and present addresses of the holders.

You must upload certified copies of such judgments and, if satisfied, satisfactions of judgments.

Name of Holder

Address 1

Address 2

City

State

ZIP Code

Country

	Additional Information

BUSINESS OWNERSHIP

Business Ownership

17.1

Are there any businesses, corporations, organizations, partnerships, professional associations, or individual partnerships in which you own or have owned a 50% or greater interest?

Litigation

17.3

Have you ever been involved in any litigation or arbitration related to the business or businesses referred to in the previous section?

Describe all litigation, including arbitration and governmental hearings, in which any business listed in the previous question has been involved. Upload documentation associated with such litigation, including the complaint, answer, and final disposition or settlement documentation.

	Explanation

17.4

Have there been had any decrees, judgments, or liens, against the business or businesses referred to in the previous section?

List any decrees, judgments, liens, or orders and amounts against business entered against the business or businesses referred to in the previous section.

	Explanation

CIVIL LITIGATION

Litigation

18.1

Have there been any instances of litigation (equity, actions at law, statutory proceedings, mental capacity, guardianship, or any other civil or administrative proceeding, other than bankruptcy) in which you have been a party or that you initiated or that was initiated on your behalf?

This question does not pertain to a class action lawsuit in which you were or are a plaintiff. You need not disclose a lawsuit or administrative proceeding that arose from you being the victim of domestic or sexual violence or harassment.

Complete the following for each instance of litigation. For each instance, upload copies of the complaint, answer, order of dismissal or judgment, and settlement agreement (if any) filed in connection with the litigation.

18.2	Civil Litigation Information

Date

Court / Agency

Case Name and Number

Name of Plaintiff

Name of Defendant

	Nature of Proceedings

	Disposition

DRIVER'S INFORMATION

Driver's License

Do you hold a driver's license?

For each jurisdiction, including Georgia, in which you have held a driver's license during the last 12 months, you must upload a CERTIFIED copy of your official driving record. The record should include the maximum number of years the state provides (seven years for Georgia) and be dated within thirty days of the submission date.

You must upload the certified driving record that you receive from the state agency. Please upload a .pdf and do not upload a screenshot. Make sure that the record includes all identifying information. We are unable to accept driving records from third-party or online vendors.

Driver's License Number

State

Date Issued

Expiration Date

Have you had another driver’s license in the last 12 months?

Driver's License Number

State

Date Issued

Expiration Date

Traffic Violations

19.1

Excluding parking violations, have you been cited or charged with more than five traffic violations within the past five years (including violations to which you were allowed to enter a "nolo contendere" plea)?

19.2	Please provide information on each of those violations to the best of your ability.

Please do not include charges of Driving Under the Influence of Drugs or Alcohol (DUI, DWI, etc.) in your answer to this question. You will be required to list those charges elsewhere.

Date

	Nature of Violation

Name of Court

Address 1

Address 2

City

State

ZIP Code

	Disposition or Status

Suspended License

19.3

Has your driver's license ever been suspended or revoked?

Name of Agency

Address 1

Address 2

City

State

ZIP Code

Country

Date of Suspension or Revocation

Length of Suspension

	Reason for Suspension or Revocation

DUI

20.1

Have you ever been charged with or cited for driving under the influence of alcohol or drugs?

Date you were charged or cited

Agency (Police Department)

Address 1

Address 2

City

State

ZIP Code

Disposition

Date of Disposition

Are you currently serving a probated sentence?

You are required to provide a detailed narrative of the facts and circumstances surrounding each offense and to upload a copy of the police report (including any citations) and all court documents for each charge.

	Facts and circumstances surrounding each offense

Have you completed all the requirements of the court?

	If you have not, explain what you have not completed and why.

CRIMINAL PROCEEDINGS

Criminal Proceedings

Before you complete this section, you must read the Policy Statement of The Board To Determine Fitness of Bar Applicants Regarding Character And Fitness Reviews, Part A - Unlawful Conduct, which you can find here.

I have read and understand this policy.

21.1

Have you ever been arrested, formally accused, cited, or prosecuted for the violation of any law?

Excluding traffic offenses, you must disclose each instance even though the charges may have been dismissed or you were acquitted or allowed to plead nolo contendere or adjudication was withheld or a conviction was reversed, set aside, or vacated or the record sealed or expunged and regardless of whether you have been told by anyone, including a judge or a lawyer, that you need not disclose any such instance. You need to disclose juvenile court activity only if you were adjudicated as delinquent for conduct that would have been designated as a felony if you were tried as an adult.

You must upload a copy of all court documents relating to each instance in which you were arrested, formally accused, cited, or prosecuted for the violation of any law.

Date of Charge

	Nature of Offense

City

State

Name of Court

Court Address

City

State

ZIP Code

	Disposition

Date of Disposition

Did this offense result in a sentence of confinement in a state prison or penitentiary for a period of one year or more, even if such sentence or imprisonment was suspended?

Did this offense result in the conviction of a felony?

Have you applied for or received a full pardon and have you received restoration of your civil rights for that crime?

	Provide a detailed narrative of the facts and circumstances surrounding each charge.

You must upload a copy of all court documents, including the indictment, plea, and final disposition.

21.6

Are you currently serving a probated sentence as a result of any criminal charge?

Indicate which charge and the date your probation is scheduled to be completed.

	Charge

Date of completion

Unauthorized Practice of Law

22.1

Have you ever been charged with or been under investigation for the unauthorized practice of law?

Provide a written explanation of each charge.

You must upload a copy of all correspondence between you and the investigative body as well as copies of that body's reports in each charge or investigation for the unauthorized practice of law.

	Explanation

Immunity

23.1

Have you ever been offered immunity from prosecution in any criminal action or criminal proceeding?

State the place, date, the name of the defendant, the nature of the act or the proceeding, the court, and the circumstances.

Place

Date

Name of Defendant

	Nature of act or proceeding

Name of Court

	Circumstances

GENERAL QUESTIONS

Preamble

The purpose of the following questions is to determine the current fitness of an applicant to practice law. All information provided in this application is kept strictly confidential. The vast majority of applicants are certified as fit to practice law; the Board on very rare occasion denies certification to applicants whose current ability to function is significantly impaired in a manner relevant to the practice of law or to applicants who demonstrate a lack of candor by their responses. This is consistent with the public purpose that underlies the Board’s responsibilities. Conversely, the Board does not deny certification to applicants based on their decision to seek treatment or support for a mental health condition. In fact, the Board encourages applicants to seek treatment if needed and believes that an applicant’s decision to obtain necessary treatment is indicative of a person who possesses the character and fitness requisite to be a member of the Bar of Georgia.

I have read and understand this Preamble.

Conditions

Within the past two years, have you had any condition or impairment (including, but not limited to, substance use, alcohol use, or a mental, emotional, or nervous disorder or condition) that would substantially inhibit your ability to practice law in a competent, ethical, and professional manner? If you have been or are being treated for a condition so that it does not currently affect your ability to practice law in a competent, ethical, and professional manner, then you need not disclose it.

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?

Note: Please be aware that you may be asked to contact your treating physician, counselor, and/or hospital and request that your records and/or a summary of your treatment be sent to the Office Bar Admissions. The Board to Determine Fitness of Bar Applicants is aware of HIPAA requirements.

	Describe the condition or impairment

	Summarize the course of the condition or impairment, including the conduct, symptoms, and circumstances that precipitated treatment.

Note: Please enter each facility and/or provider as a separate entry. Use the "Add More" button at the bottom of the page to add additional providers.

Name of attending Physician or Counselor

Name of Hospital or Institution

Address 1

Address 2

City

State

Zip Code

	Description of any treatment and/or monitoring program, dates of treatment, and results of treatment.

Functioning

Has your functioning at school or at work ever been sufficiently impaired (as the result of substance abuse, alcohol abuse, or a mental, emotional, or nervous or behavior disorder or condition) as to require inpatient treatment?

	Describe the condition or impairment

Provide the dates of treatment.

Start Date

End Date

	Summarize the course of the condition or impairment, including the conduct, symptoms and circumstances that precipitated treatment.

Note: Please enter each facility and/or provider as a separate entry. Use the "Add More" button at the bottom of the page to add additional providers.

Name of attending Physician or Counselor

Name of Hospital or Institution

Address 1

Address 2

City

State

Zip Code

	Description of any treatment and/or monitoring program, dates of treatment, and results of treatment.

Condition Used as Defense

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?

You must upload copies of all pertinent records with regard to your answer.

	Provide an explanation, including all relevant dates.

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

Address 1

Address 2

City

State

ZIP Code

	Disposition, if any

Date of Disposition

Other Licenses

Excluding a license to practice law, have you ever applied for a state or local license in order to pursue a career, such as a real estate license, a professional license, etc.?

License Type

Licensing Agency

Agency Address

City

State

ZIP Code

Application Date

Were you required to show proof of good character?

Was an Exam Required?

Was the license issued?

Date License was Issued

License Number

Is the license currently valid?

	Provide a full explanation as to why the license is no longer valid.

	Please explain the reason for non-issuance

Disciplinary Proceedings

Have any disciplinary proceedings been instituted against you on behalf of any licensing agency?

Name of person or agency instituting proceedings

Address 1

Address 2

City

State

ZIP Code

	Disposition

REFERENCES

Personal References

Provide the names and email addresses of five personal references who have known you well within the past five years. To expedite processing of your application, we recommend that you contact your personal references after you receive a message from your fitness analyst informing you that your application has been assigned to them. You should let your references know to be on the lookout for an email from noreply@gabaradmissions.org, and that they should check their spam folder if they don't receive it within 24 hours after you receive the initial message from your analyst.

Do not list:

a) your spouse or any other relative (including an in-law);
b) current roommate;
c) any current fellow student at your law school;
d) your present or former employer or supervisor;
e) more than one professor at your law school; or
f) more than one member of the same household.

Prefix

First Name

Last Name

Email Address