<p> 2017 PANEL APPLICATION FORM For Current Panel Members making reapplication ONLY Application must be received by December 31, 2016</p><p>IDENTIFYING INFORMATION (LRIS listings are by individual attorney, not law firm/affiliation) Last Name: First Name: MI: Firm Name: Website: Business Address: Suite: Business City: State: Zip: Business Phone: Fax: Cell: Email:</p><p>I understand that membership in the Hennepin County Bar Association (HCBA) and the Lawyer Referral and Information Service (LRIS) is a requirement of serving on the Commitment Defense Panel. I understand that any lapse in my membership in either organization, or any lapse of my malpractice insurance, will result in my suspension from the panel. I understand that the LRIS staff will monitor the expiration date of my insurance and require a copy of the new declaration page on renewal. </p><p>I am presently not under suspension or probation, either public or private, by the Minnesota Supreme Court. I authorize the Commitment Defense Project to verify my disciplinary status with the appropriate boards. </p><p>I understand that appointments to the commitment defense attorney panel are made by an independent advisory panel. This appointment to the CDP Panel is for the period ending March 31, 2018. I understand that each year I must reapply for the panel, and that past membership on the panel does not guarantee reappointment.</p><p>If appointed, I will agree to serve as an advocate for my clients and will familiarize myself with alternatives to commitment and available resources.</p><p>I agree to the hourly compensation rate and will comply with the CDP billing procedures and policies. Except in unusual circumstances, any bill not submitted for payment within 60 days of the services rendered may not be paid. Any bill exceeding $600 will be separately justified in writing.</p><p>I will attend CDP meetings and seminars. I understand that panel members are expected to attend eight monthly CDP meetings during 2017-2018, and attendance at education seminars will be taken into consideration for re-appointment to the panel.</p><p>Please check the box next to each of the meetings you attended in 2016: 1/21/16 EMRS Use 600 NICOLLET MALL, SUITE 390, MINNEAPOLIS, MN 55402 PHONE: 612-752-6600 FAX: 612-752-6601 2/18/16 Motions to Seal Court Files 3/18/16 Somalian Diversity 4/21/16 Elimination of Bias 5/20/16 Ethics 6/22/16 Presiding Judge Transition 7/22/16 Steven Pratt MD 8/17/16 Commitment Rule Changes 9/23/16 PPSU Update 10/20/16 Mental Illness & Disability Statutory Proposals 11/18/16 New County Treatment Units 12/22/16 To Be Announced</p><p>Additional training that you attended that is relevant to Commitment Defense Project:</p><p>By checking the boxes below, I am certifying that: I am a member of the HCBA in good standing for the 2016-2017 year. I will maintain membership in the HCBA LRIS for the upcoming year. I have current legal malpractice insurance and that a copy of the declaration page of my malpractice insurance is either attached or currently on file with the LRIS. I will maintain malpractice coverage during my term on the Commitment Defense Panel.</p><p>Signature : Date:</p><p>MN Attorney Registration Number:</p><p>600 NICOLLET MALL, SUITE 390, MINNEAPOLIS, MN 55402 PHONE: 612-752-6600 FAX: 612-752-6601</p>