APPLICATION FOR CERTIFIED BANKRUPTCY ASSISTANT

Please complete the application in its entirety and comply with all of its instructions. If you have any questions, please email Debbie Reese at debbie_reese@gas.uscourts.gov.

I. GENERAL INFORMATION

An * indicates a required response.

First Name *

Last Name *

Mailing Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

II. LEGAL EMPLOYMENT

Current Employer *

Start Date (mm/yyyy) *

Street Address *

City *

State *

Zip Code *

Title (Position) *

Phone Number *

Previous Employer

Start Date (mm/yyyy)

End Date (mm/yyyy)

Street Address

City

State

Zip Code

Title (Position)

Phone Number

Previous Employer

Start Date (mm/yyyy)

End Date (mm/yyyy)

Street Address

City

State

Zip Code

Title (Position)

Phone Number

III. EDUCATION/CERTIFICATIONS

College or Law School Attended

From

To

Degree

College or Law School Attended

From

To

Degree

List any certifications.

Subject/Certification Granted

State

Date of Certification (mm/yyyy)

Subject/Certification Granted

State

Date of Certification (mm/yyyy)

How long has applicant worked in the bankruptcy field?

Years *

IV. REFERENCES

Name bankruptcy attorney(s) familiar with applicant's work. The CBA Committee reserves the right to contact the attorney/employer for verification of all information provided by the applicant.

Reference 1

First Name

Last Name

Company Name

Phone Number

Street Address

City

State

Zip Code

Reference 2

First Name

Last Name

Company Name

Phone Number

Street Address

City

State

Zip Code

V. COVENANTS

CBA Rules and Regulations for Bankruptcy Certification

Written Disclosure. The Certified Bankruptcy Assistant Program (CBA Program) provides a general background in bankruptcy law and writing skills. Its purpose is to enhance an individual's work skills and to assist them in their professional career, specifically in the bankruptcy field. Upon successful completion of the CBA Program, an individual may become a Certified Bankruptcy Assistant (CBA).

The CBA Program, CBA Certification, and the provided study guide are neither designed nor intended to qualify an individual to practice law, sign legal documents, or teach any of the course materials to anyone for any purpose.

A.   I have read and understand the Written Disclosure and the Rules and Regulations for CBA Certification by the Association of Bankruptcy Judicial Assistants. I certify that I am fully qualified for participation in the CBA Program, and I know of no reason why, upon successful completion of the CBA Program, I am not entitled to become a Certified Bankruptcy Assistant. Further, I understand that my application may be rejected if I do not meet the requirements as outlined in the Rules and Regulations for CBA Certification.

B.   I agree to provide all relevant documents, or other pertinent information that may be requested from me by authorized personnel of the Association of Bankruptcy Judicial Assistants so that my application may be processed.

C.   I authorize any person named on my application to provide any pertinent information that may be needed to verify any information contained in my application.

I Agree - Yes or No *

/s/ Applicant's Electronic Signature (by typing name)

Date (mm/dd/yyyy)

/s/ Supervisor's Electronic Signature (by typing name)

Date (mm/dd/yyyy)