Attachment B

Name*

First NameLast Name
Email*
Exam*

FebruaryJulyN/A - Limited Practice Application
Exam/application year:*
Complete Title of Action
Court File Number
Date(s) the claim/action was filed
Court or entity with possession of documents information
Name of court or entity with possession of documents:
Address and phone number of court or entity with possession of documents:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Professional liability company information (if applicable)
Name of professional liability company (if applicable):
Address and phone number of professional liability company (if applicable):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Plaintiff Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Plaintiff's Attorney Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Defendant Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Defendant's Attorney Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Trial Date

MonthDayYear
Date
Date of Final Disposition

MonthDayYear
Date
Disposition
Narrative summary of the civil action/claim including a description of all alleged causes of action and defenses raised: (For Bankruptcy proceedings, please provide a description of the circumstances leading up to and surrounding the filing of any such proceeding)
If the disposition resulted in a judgment, has the judgment been satisfied?

YesNo
If yes, give the date the judgment was satisfied and attach evidence of the same:

MonthDayYear
Date
If no, what amount is still owing and why:
Attach copies of all evidence including: pleadings, petitions, schedules, discharges, objections to discharge, adversary proceedings, judgments and/or final orders.

Cancelof
Should be Empty: