C O N F I D E N T I A L

FEDERAL JUDICIAL APPOINTMENTS

PERSONAL HISTORY FORM

PROVINCIAL/TERRITORIAL COURT JUDGE

1.	Complete the attached Personal History Form and Authorization Form. The forms must be dated and signed. Do not write on the back of pages. A recent photograph is optional. Attach a copy of the instrument appointing you to your current judicial office (or other documentary evidence of that appointment).

2.	Provide any additional information which you believe useful. If the space provided in the Personal History Form is not sufficient you may supplement it by attaching additional numbered pages. A curriculum vitae can also be attached but not as a substitute for completing the form.

3.	Remove this top page and return the completed Personal History Form and other material to:

Executive Director, Judicial Appointments

Office of the Commissioner for Federal Judicial Affairs

99 Metcalfe St., 8th Floor

Ottawa, Ontario K1A 1E3

Telephone: (613) 992-9400

Toll free: 1-877-583-4266

Fax: (613) 941-0607

PLEASE NOTE

The Personal History Form and other material received will be submitted to the appropriate Advisory Committee in your province or territory for comments which will be reported to the Minister of Justice. These comments are not binding on the Minister and your name will be placed on the list of those available for appointment. Committee Reports are confidential and communicated to the Minister only.

All information will be kept in confidence. The Advisory Committee may consult both within and outside any sources provided in the form. When making inquiries, all efforts will be made to maintain confidentiality; the Committee, however, cannot accept responsibility for any unauthorized disclosure of an applicant's name.

For security reasons, do not FAX or E-Mail this document

MARCH 2006

C O N F I D E N T I AL

PERSONAL HISTORY FORM

PROVINCIAL/TERRITORIAL COURT JUDGE

Surname:

Given Names:

Date of Birth (D/M/Y):

Male Female

Citizenship:

PLACE OF BIRTH

City:	Province/Territory (if applicable):

Country:

BUSINESS ADDRESS

Name of court:

Number, street, suite:

USE AS MAILING ADDRESS

City, prov./terr., postal code:

Telephone (area code & number):

Fax: area code & number:

RESIDENCE ADDRESS

Number, street, apt.:

City, prov./terr., postal code:

USE AS MAILING ADDRESS

Telephone (area code & number):

Fax (area code & number):

E-mail

Address:

Have you previously submitted your name for consideration for a federal judicial appointment? If so, please give the date and jurisdiction (province or territory) of your prior submission.

NO YES

Date:

Jurisdiction:

Past or present membership in the Bar of:

Dates of membership:

Past or present membership in other Bars:

Dates of membership:

Date of appointment to your court:

Primary location and Judicial Region of your court:

City, town:

Judicial Region :

CANDIDATE FOR

Select one province or territory only. Except for the territories, you must be a member of the bar of the jurisdiction for which you submit the form. If you wish to be a candidate in more than one province or territory, please submit a separate and complete Personal History Form for each province or territory.

ALBERTA
Court of Appeal
Court of Queen's Bench

BRITISH COLUMBIA
Court of Appeal
Supreme Court

MANITOBA
Court of Appeal
Court of Queen's Bench
Court of Queen's Family

NEW BRUNSWICK
Court of Appeal
Court of Queen's Bench - Trial
Court of Queen's Family

NEWFOUNDLAND AND LABRADOR
Supreme Court - Appeal
Supreme Court - Trial

NORTHWEST TERRITORIES
Supreme Court

NOVA SCOTIA
Court of Appeal
Supreme Court
Supreme Court (Family Division)

NUNAVUT
Nunavut Court of Justice

ONTARIO
Court of Appeal
Superior Court of Justice
Family Court - Superior Court of Justice

PRINCE EDWARD ISLAND
Supreme Court - Appeal
Supreme Court - Trial

QUÉBEC
Court of Appeal
Superior Court

SASKATCHEWAN
Court of Appeal
Court of Queen's Bench
including Family Law Division

YUKON
Supreme Court

FEDERAL COURTS*
Federal Court of Appeal
Federal Court

TAX COURT OF CANADA*

*Please note that judges of the Federal Court, Federal Court of Appeal, or the Tax Court of Canada are required by statute to be resident in the National Capital Region; accordingly, if you wish to be considered for either of these courts and you live outside the NCR, you will be required to move your residence. This represents a significant change in lifestyle for you and your family, and the impact of this requirement should be seriously considered before applying for these courts.

PLACE OF RESIDENCE

If appointed, I would be willing to reside:

Anywhere in the province or territory

Only in (please be specific) :

In the National Capital Region (required for candidates for Federal Court,

Federal Court of Appeal or Tax Court of Canada)

TRAVEL

If appointed, I would be willing to travel within the province or territory or within Canada,

as required by the Chief Justice. (Please note that travel may be required more often for the Federal Court, the Federal Court of Appeal, or the Tax Court of Canada.)

YES NO

Comments:

LANGUAGE(S)

Language(s) in which you are competent to hear and conduct a trial:

English French Other

Comments:

Official language of preference for correSpondence :

English French

EDUCATION

Name of institution, years attended, degree/diploma and year obtained.

Postgraduate:

Law School:

University:

Continuing Education:

Academic awards:

PROFESSIONAL AND EMPLOYMENT HISTORY

Please provide information on your past legal work experience, and on your main areas of adjudication

since the appointment to your court.

Other professional responsibilities, publications:

PERSONAL & OTHER MATTERS

Where you answer yes, please provide a detailed explanation, using additional pages if required

Ever disciplined by a Law Society or a Judicial Council, or by another professional association or regulatory body? Are there currently any disciplinary actions or investigative measures being taken against you?

YES NO

Ever found guilty of a criminal or other offence by a court or tribunal? Are you currently defending a

charge for such an offence?

YES NO

Are you involved in litigation in your own name, as plaintiff or defendant, at this time? If not, do you foresee commencing or defending any such litigation?

YES NO

Are you insolvent, in financial difficulties or subject to potential financial claims?

YES NO

Have you ever declared bankruptcy (if so, provide, all relevant information including the amounts involved, the list of creditors and the certificate of release)?

YES NO

Are you in arrears with taxes owed to a federal, provincial, territorial or municipal government?

YES NO

Are you in default of a family support obligation?

YES NO

Have you had any debilitating physical or mental health problems, including alcohol or

drug problems, in the last 10 years?

YES NO

Is there anything in your past or present which could reflect negatively on yourself or the judiciary,

and which should be disclosed?

YES NO

OPTIONAL

Given the goal of ensuring the development and maintenance of a judiciary that is representative of the diversity of Canadian society, you may, if you choose, provide information about yourself that you feel would assist in this objective. There is no obligation to do so.

REFERENCES

If you wish, list the names of persons who may be consulted by the Committee concerning your candidature, together with the information requested below for each. Please ensure that your references are aware that they may be contacted by the Committee regarding your application.

1. Name:

Occupation:

Address:

Business telephone: Home telephone:

E-Mail:

2.Name:

Occupation:

Address:

Business telephone: Home telephone:

E-Mail:

3. Name:

Occupation:

Address:

Business telephone: Home telephone:

E-Mail:

4. Name:

Occupation:

Address:

Business telephone: Home telephone:

E-Mail:

ATTESTATION AND SIGNATURE

I, , attest to the veracity of the information provided in this

(please print)

Personal History Form.

(Candidate's signature)	(Date)