Fill and Sign the Change of Information Selective Service

Nebraska Revised 12/27/2016 ASD 3:15 1 APPLICATION TO THE BAR OF NEBRASKA (Jurisdiction) Name First Middle Last Suffix Social Security Number* NCBE Number If you ne ed to make any changes to your name, date of birth and/or Social Security Number y ou must do so by updating your NCBE Number information . APPLYING to reinstate from: Suspension Date of suspension: _______________ Inactive Status taken: __________________ T HE FOLLOWING Q UESTIONS SEEK INFORMATION FROM T HE TIME YOU WERE LAST ACTIVELY LICENSED T O T HE PRESENT UNLESS OTHERWISE INDICATEDList below all the other names or surnames you have used or been known by, and describe when, how, and why your name was changed ( e.g., marriage or divorce). ■ First, Middle, Last Name, Suffix From Mo/Yr To Mo/Yr Reason for change ■ First, Middle, Last Name, Suffix From Mo/Yr To Mo/Yr Reason for change Telephone numbers and an e-mail address at w hich you can be reached during the next six months: ( ) ( ) Mobile or Home Office E-mail Mailing address at which you c an be contacted about this application during the next six months: Check if address is Residence or Business If business, name of firm: Address/P.O Box: Nature of business being performed: C ity S tate Zip C ountry Province Nebraska Revised 12/27/2016 ASD 3:15 2 DIRECTIONS Any questions regarding this application or the bar exam must be made in writing to: nsc.attyadmissions@nebraska.gov PREAMBLE The Nebraska Supreme Court (Court) exercises jurisdiction over admission to the practice of law in the state of Nebraska. T he Court established the Nebraska State Bar Commission (Commission) to review all applicants and make recommendations t o the Court for admission. See Neb. Ct. R. §3-100. The Commission is charged with conducting an investigation into each applicant’s moral character and fitness to practice law. The objective of character and fitness screening is to protect the public and to safeguard the legal system. T he purpose of inquiries into the applicant’s background is to produce information necessary to evaluate the applicant’s ch aracter and fitness. See Neb. Ct. R. §3-116. It is the applicant’s responsibility to provide information as requested by the Commission to demonstrate the applicant meets the requirements for the practice of law as set forth by the Nebraska Supreme Court. See Neb. Ct. R. §3- 125. The Commission conducts a thorough and extensive background investigation. Failure to disclose relevant information w ill have serious consequences. Information gathered in the course of the investigation is for the limited purpose o f determining an applicant’s eligibility to practice law and is subject to rules of confidentiality set forth by the Nebraska Supreme Court. See Neb. Ct. R. §3-127. I have read the above. Nebraska Revised 12/27/2016 ASD 3:15 3 RESIDENCE INFORMATION Make additional copies of this page as necessary. 1. List every permanent or temporary physical address where you have resided for a period of one month or longer in reverse chronological order for the relevant t ime period: From Mo/Yr Current Address S treet Addre ss City County State Zip Country Province ■ From Mo/Yr To Mo/Yr S treet Address City County State Zip Country Province ■ From Mo/Yr To Mo/Yr S treet Address City County State Zip Country Province ■ From Mo/Yr To Mo/Yr S treet Address City County State Zip Country Province ■ From Mo/Yr To Mo/Yr S treet Address City County State Zip Country Province ■ From Mo/Yr To Mo/Yr S treet Address City County State Zip Country Province Nebraska Revised 12/27/2016 ASD 3:15 4 EDUCATION INFORMATION Make additional copies of this page as necessary. Field(s) of Study 2. List complete information regarding your attendance at law schools/colleges/universities where you have studied or are currently studying law since you were last actively licensed. 3. Law S chool Mailing Address City Zip Country Province From Mo/Yr To Mo/Yr State Date degree received or expected (Mo/Yr) Degree received or expected to be received (No Degree, LL.B., LL.M., etc.) Nebraska Revised 12/27/2016 ASD 3:15 5 EDUCATION INFORMATION 6 ADMISSION INFORMATION 4. OTHER APPLICATIONS F OR ADMISSION AND AUTHORIZATION TO PRACTICE Have you submitted an application for bar admission, applied as a foreign legal consultant or in-house counsel, or been admitte d, lic ensed, or authorized to practice law in any U.S. jurisdiction (state, territory, or the District of Columbia), tribal court, or foreign jurisdiction, including admission to the bar by examination, motion, or diploma privilege? (DO NOT include information regarding admission to the U.S. federal courts or authorizations to appear pro hac vice.) If yes for the relevant time period, list every U.S. or foreign jurisdiction, including tribal cour t, to which you have: Yes No • submitted an application to pre-register as a law student, take a bar examination, register as a foreign legal consultant or in-house counsel, or be admitted to a bar or tribal court on motion. • been admitted, registered, licensed, or authorized to pr actice law. • submitted an application to be reinstated to a bar or tribal court. Multiple applications and examinations in a U.S. jurisdiction, tribal court, or foreign jurisdiction require separate entries. Provide a brief narrative explanation of the circumstances surrounding the reason for any withdrawals of applications or failures to be admitted (other than those due to failing the examination). If admitted to the ba r of New