House Counsel Application- For Attorneys Only

Please check one:

New Applicant
Annual Renewal
Reinstatement

Applicant Information

FIRST NAME:

MIDDLE NAME:

LAST NAME:

BUS. ADDRESS:

CITY:

STATE:

ZIP CODE:

BUSINESS PHONE:

FAX:

CELL PHONE(XXX-XXX-XXXX):

E–mail*

DATE OF ADMISSION INTO THE STATE BAR OF MICHIGAN:

BAR NUMBER:

NATURE OF YOUR PRACTICE

DISTRICT COURT %:

TRAFFIC/CRIMINAL %:

CIVIL %:

CIRCUIT COURT %:

CRIMINAL %:

CIVIL %:

ARE YOU FLUENT IN A SECOND LANGUAGE?

YES
NO

IF YES, LIST LANGUAGE:

HAVE YOU EVER HAD A REQUEST FOR INVESTIGATION FILED AGAINST YOU WITH THE STATE ATTORNEY GRIEVANCE COMMISSION AND/OR HAVE YOU EVER BEEN DISCIPLINED BY THE ATTORNEY DISCIPLINE BOARD IN MICHIGAN OR ANY OTHER STATE? IF YES, PLEASE PROVIDE A DETAILED STATEMENT OF FACTS INCLUDING FINAL RESOLUTION WITH YOUR APPLICATION.

YES
NO

PREVIOUS POSITIONS WITHIN THE JUSTICE SYSTEM