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2. 
3. For Questions Contact:
   Humboldt County Administrative Office
   Management & Budget Team
   825 5th Street, Suite 112, Eureka, CA 95501-1153
   Telephone (707) 445-7266 Fax (707) 445-7299
   cao@co.humboldt.ca.us
5. Documents You Will Need to Have Ready to Upload to Complete This Application:
   - Resume with relevant work history
   - Entrance and Renewal Certificate
   - Also, please read the HCAAP Rate Schedule as it includes the rules around the HCAAP program.
7. Legal Name*
8. Tax ID#*
10. Firm Name:*
12. Street Address*
    No PO Boxes
13. Mailing Address*
    May include PO Box
15. City, State
16. Zip Code
17. City, State
18. Zip Code
20. Contact Phone Number:*
21. Contact Email:*
25. ADMISSION TO BAR
27. CA BAR #*
28. Date Admitted to CA BAR*
29. Years in Practice*
31. Are you a Criminal Law Specialist?*

    1. Yes
    2. No
32. If Yes, date certified/recertified:
34. Admitted in other states?*

    1. Yes
    2. No
35. If Yes, states and year admitted:
37. Member of other court appointed attorney programs?*

    1. Yes
    2. No
38. If Yes, list county(ies) and years:
42. EMPLOYMENT HISTORY
    Please check off areas of previous employment. Details of this work must be reflected in your resume.
44. Which positions have you held in the past or do you currently hold?*

    1. Deputy Public Defender
    2. State Defender
    3. Federal Defender
    4. Appellate Defender
    5. Private Law Firm
    6. Deputy District Attorney

    1. Deputy City Attorney
    2. Assistant U.S. Attorney
    3. Military Attorney
    4. Solo Practitioner
    5. Other (describe)
46. Other:
48. Resume:*
    Attach a resume
49. Training and Case Certification:*
    Attach complete Entry and Renewal Certification Form declaring that you meet the training and case requirements of the attorney class for which you are applying.
53. Panels
    Please select all the panels you are applying for.
55. Adult Criminal*

    1. Class 1
    2. Class 2
    3. Class 3
    4. Class 4
    5. Contempt
    6. Misdemeanor Appeals
56. Juvenile/602 Cases

    (including probation violations)

    1. Class 1J
    2. Class 2J
    3. Class 3J
    4. Class 4J
60. DECLARATION OF ELIGIBILITY
62. I, *
64. hereby declare:
    1. I am an active member in good standing with the State Bar of California and am not now nor have been, in the immediately preceding twelve (12) months, subject to any State Bar discipline (including but not limited to probation, suspension, disbarment or failure to pay State Bar dues, or comply with MCLE requirements);
    2. I maintain my principal office in Humboldt County at the address specified below, the majority of my practice is in Humboldt County, and this is my address of record with the State Bar of California;
    3. I have listed above the name(s) of the other criminal, juvenile defense, post- conviction and/or federal court appointment panels to which I belong;
    4. I hereby certify that I have completed at least six (6) hours of criminal law education or training in the immediately preceding twelve (12) months;
    5. I acknowledge that I have received and read the Appointed Attorneys Program (HCAAP) Rate Schedule adopted by the Board of Supervisors on March 12, 2019 and revised June 13, 2019 (available on the Humboldt County website) and the rules and regulations set forth therein. I agree to abide by and be bound by the Fee Schedule.
    6. I hereby consent to verification by HCAAP of my eligibility for membership in HCAAP.
    7. I hereby waive any and all claims, known or unknown, which I may now have against the County of Humboldt, its officers, directors, members, employees and the HCAAP Advisory Committee members for any liability or loss arising out of the operation of HCAAP, application of the Governing Rules, or from the referral or non- referral, assignment or non-assignment, of any case thereunder;
    8. I hereby agree to hold harmless and indemnify the HCAAP, its officers, directors, members and employees and the County of Humboldt, its Board of Supervisors, employees and agents from any and all claims, demands, actions, liability, or loss which may arise or be incurred because of or resulting from my participation or lack of participation in HCAAP;
    9. I agree that this participation Agreement is renewable each calendar year and that the terms and conditions which apply to the member shall be subject to changes as HCAAP deems necessary.
    10. I understand that as a HCAAP panel member, I am receiving reimbursement for legal services rendered; I am an independent contractor. I am not an employee of the County of Humboldt. No relationship of employer and employee is created by this Agreement; it being understood and agreed that attorney is an independent contractor. Contractor is not the agent or employee of the County of Humboldt in any capacity whatsoever and the County of Humboldt shall not be liable for any acts or omissions by attorney nor for any obligations or liabilities incurred by attorney. Attorney shall have no claim under this Agreement or otherwise, for seniority, vacation time, vacation pay , sick leave, personal time off, overtime, health insurance medical care, hospital care, retirement benefits, social security, disability, Workers’ Compensation, or unemployment insurance benefits, civil service protection, or employee benefits of any kind.
    11. Attorney, by this Agreement, agrees to perform his/her work in strict accordance with currently approved methods and practices in his/her field. Attorney further agrees that the sole interest of the County of Humboldt is to insure that said service shall be performed and rendered in a competent, efficient, timely and satisfactory manner and in accordance with the standards required by the State Bar of California and the Humboldt County Criminal Court Appointed Attorneys Program.
    12. The County of Humboldt has and reserves the right to remove any attorney from the HCAAP panel. If removed, the Attorney shall be entitled to payment for services provided hereunder prior to the effective date of said removal.
    13. The parties agree that any and all disputes, claims or controversies arising out of or relating to the HCAAP Participation Agreement shall be submitted to JAMS, or its successor, for mediation, and if the matter is not resolved through mediation, then it shall be submitted to JAMS, or its successor, for final and binding arbitration pursuant to the clause set forth in Paragraph 17 below.
    14. Either party may commence mediation by providing to JAMS and the other party a written request for mediation, setting forth the subject of the dispute and the relief requested.
    15. The parties will cooperate with JAMS and with one another in selecting a mediator from the JAMS panel of neutrals and in scheduling the mediation proceedings. The parties agree that they will participate in the mediation in good faith and that they will share equally in its costs.
    16. All offers, promises, conduct and statements, whether oral or written, made in the course of the mediation by any of the parties, their agents, employees, experts and attorneys, and by the mediator or any JAMS employees, are confidential, privileged and inadmissible for any purpose, including impeachment, in any arbitration or other proceeding involving the parties, provided that evidence that is otherwise admissible or discoverable shall not be rendered inadmissible or non-discoverable as a result of its use in the mediation.
    17. Either party may initiate arbitration with respect to the matters submitted to mediation by filing a written demand for arbitration at any time following the initial mediation session or at any time following 45 days from the date of filing the written request for mediation, whichever occurs first (“Earliest Initiation Date”). The mediation may continue after the commencement of arbitration if the parties so desire.
    18. At no time prior to the Earliest Initiation Date shall either side initiate an arbitration or litigation related to this Agreement except to pursue a provisional remedy that is authorized by law or by JAMS Rules or by agreement of the parties. However, this limitation is inapplicable to a party if the other party refuses to comply with the requirements of Paragraph 15 above.
    19. All applicable statutes of limitation and defenses based upon the passage of time shall be tolled until 15 days after the Earliest Initiation Date. The parties will take such action, if any, required to effectuate such tolling.
    I declare, under penalty of perjury, the foregoing to be true and correct of my own information, knowledge and belief and that I have knowingly, intelligently and voluntarily consented to the foregoing provisions.
66. Terms of Acceptance and Signature
    I, the applicant for the Humboldt County Court-Appointed Attorney Program, warrant the truthfulness of the information provided in this application.
68. Electronic Signature*
    Please type your first and last name
69. Executed on *
70. at*
72. Confirmation

    1. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above declarations and all portions of this application.
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74. 1. Receive an email copy of this form.
75. Email address

    This field is not part of the form submission.

76. Submit Submit and Print

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