Application for Approval to Provide Legal Aid Services_VERSION 2 Page 1 / 11

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1 Application for Approval to Provide Legal Aid Services Part 1 Please use this form if you are seeking approval as a provider of legal aid services, (lead provider, supervised provider or an employment advocate) or as a provider of specified legal services under section 77 of the Legal Services Act Please refer to the APPLICATION FOR APPROVAL TO PROVIDE LEGAL SERVICES GUIDELINES for clarification on the terms used and assistance with completing this application. Please provide an original or certified copy of your Certificate of Standing and copies of any documentary evidence in support of your application, as originals will not be returned. Please note, incomplete applications or applications not in the prescribed format will be returned. Please do not bind your application, and if possible submit your application single sided. You may complete this form online or print and complete, however you must submit a signed hard copy of your application. 1. If you complete the form/s online, please ensure that you print the relevant forms and then complete the Statutory Declaration. Send form/s and the supporting documentation to the address outlined on p8 of this form. 2. If you print and complete the form/s, please ensure that you complete the relevant form/s, and send them with supporting documentation to the address outlined on p8 of this form. If you run out of space on the form/s, please attach the additional information to the form/s. Please review the Checklist in the Guidelines to ensure you have attached all the required supporting documentation. This application is in four parts: Part 1 Information about you, your systems and your work experience history Part 2 Areas of law Information about your experience and competence, case examples and work samples Part 3 References Forms 3A and 3B Part 4 Supervision arrangements. If you are applying for approval as a lead provider or as a provider of specified legal services, you must submit: An original or certified copy of your Certificate of Standing (please note that it must be valid when the Ministry of Justice receives your application). Part 1 Information about you, your systems and your work experience history Part 2 A completed area of law form for each area of law for which you are seeking approval including: the prescribed number of case examples and work samples for each area of law Part 3 Reference/s completed in the prescribed format (Form 3A) Please note, if you are applying for approval in one area of law only, you will need at least two references. If you are applying for approval in more than one area of law, you must provide at least one reference for each area of law for which you are applying Part 4 NOT REQUIRED. Application for Approval to Provide Legal Aid Services_VERSION 2 Page 1 / MOJ Part 1-Provide Legal Aid Form_4jb.indd 1 26/10/11 5:21 PM

2 If you are applying for approval as a supervised provider, you must submit: An original or certified copy of your Certificate of Standing (please note that it must be valid when the Ministry of Justice receives your application). Part 1 Information about you, your systems and your work experience history Part 2 NOT REQUIRED Part 3 Reference/s completed in the prescribed format (Form 3B) Please note, if you are applying for approval in one area of law only, you must provide at least two references. If you are applying for approval in more than one area of law, you must provide at least one reference for each area of law for which you are applying Part 4 Evidence of employment as a lawyer or evidence of adequate supervision arrangements (see Application Guidelines) If you are applying for approval as an employment advocate, you must submit: Documentary evidence of membership of the Employment Law Institute of New Zealand Inc. Part 1 Information about you, your systems and your work experience history Part 2 NOT REQUIRED Part 3 At least two reference/s completed in the prescribed format (Form 3A) Part 4 NOT REQUIRED. Areas of law for which you are seeking approval Please ensure you mark your preferences clearly. Legal Aid Services I am applying for approval as a lead provider in the following areas of law: Civil Criminal Proceedings Category 1 Criminal Proceedings Category 2 Criminal Proceedings Category 3 Criminal Proceedings Category 4 Family Mental Health Māori Land and Māori Appellate Courts, and Waitangi Tribunal Refugee and Immigration Court of Appeal and Supreme Court Employment advocate Application for Approval to Provide Legal Aid Services_VERSION 2 Page 2 / MOJ Part 1-Provide Legal Aid Form_4jb.indd 2 26/10/11 5:21 PM

3 Specified Legal Services Duty Solicitor Police Detention Legal Assistance I am applying for approval as a supervised provider in the Civil following areas of law: Criminal Family Mental Health Māori Land and Māori Appellate Courts, and Waitangi Tribunal Refugee and Immigration Part 1 Section 1 Information about you, your systems, and your work experience history a) Your details Title Mr Mrs Ms Miss Dr Other Surname First name/s Preferred first name Name of your practice /employer How many Lawyers / legally qualified staff are employed at the firm? Contact details Direct dial number Mobile phone number Fax number Direct business for all correspondence Street address Postal address DX address Application for Approval to Provide Legal Aid Services_VERSION 2 Page 3 / MOJ Part 1-Provide Legal Aid Form_4jb.indd 3 26/10/11 5:21 PM

4 b) Current approval status for the provision of legal services Are you currently approved as a legal aid provider? Yes No (If no, go to Part 1, Section 2) If yes, what is your provider number? Your current approvals as a lead provider (please tick) Civil Criminal Proceedings Category 1 Criminal Proceedings Category 2 Criminal Proceedings Category 3 Criminal Proceedings Category 4 Duty Solicitor Family Mental Health Māori Land and Māori Appellate Courts Waitangi Tribunal Police Detention Legal Assistance Refugee Supreme Court Employment Advocate Your current approvals as a secondary provider Civil Criminal Family Mental Health Māori Land and Māori Appellate Courts Waitangi Tribunal Refugee Do you have any conditions attached to your listing approval/s? Yes No If yes, please provide details: Application for Approval to Provide Legal Aid Services_VERSION 2 Page 4 / MOJ Part 1-Provide Legal Aid Form_4jb.indd 4 26/10/11 5:21 PM

5 Part 1 Section 2 Professional entry requirements If you are applying for approval as a lawyer: Do you have a current practising certificate? Yes No Please attach an original or certified copy of your Certificate of Standing (please note that it must be valid when the Ministry of Justice receives your application) a) Is your practising certificate subject to any conditions? Yes No If yes, please provide details b) Has the NZLS, the Legal Services Agency or the Ministry of Justice upheld or substantiated any complaints about you? Yes No If yes, please provide details If you have upheld NZLS complaints, please provide a copy of the NZLS Determination letter or decision. c) Have your approvals ever been suspended or cancelled? Yes No If yes, please provide details d) Have you ever been convicted of any offence not covered by the Clean Slate Act 2004? Yes No If yes, please provide details Application for Approval to Provide Legal Aid Services_VERSION 2 Page 5 / MOJ Part 1-Provide Legal Aid Form_4jb.indd 5 26/10/11 5:21 PM

6 If you are applying for approval as an employment advocate: Are you a member of the Employment Law Institute of New Zealand? Yes No Explanatory note: Employment advocates applying for approval as a provider are required by regulations to provide evidence of their membership in the ELINZ. Please attach evidence of membership Part 1 Section 3 Your service delivery systems The Legal Services (Quality Assurance) Regulations 2011 requires providers to have service delivery systems that ensure the provision of legal aid services or specified legal services in an effective, efficient and ethical manner. The information you provide in this section allows us to assess your service delivery systems. These systems enable providers to: Meet and manage client service requirements and expectations Manage client complaints Invoice accurately Manage scheduling conflicts Manage conflicts of interest Maintain accurate records. a) Client care How do your clients normally contact you? What arrangements do you have in place when your client is unable to contact you directly? Where do you meet with your clients? Application for Approval to Provide Legal Aid Services_VERSION 2 Page 6 / MOJ Part 1-Provide Legal Aid Form_4jb.indd 6 26/10/11 5:21 PM

7 What back-up arrangements do you have for illness, holidays and scheduling conflicts? How do you manage complaints from clients? What arrangements / processes do you have in place to identify / manage potential conflicts of interest? If you work as a Barrister sole or as a sole practitioner, please include the names and phone numbers of the providers who assist you in delivering these services. Please supply a copy of your Client Care letter and your letter of engagement b) Administrative support Do you have administrative support? Yes No If no, how do you ensure accurate file management? c) Time Recording and Accounts systems Please provide the name or a description of your arrangement or systems for managing the following: Time recording If electronic, name of software Standard or custom built? If paper, description of system: Accounts If electronic, name of software Standard or custom built? If paper, description of system: Application for Approval to Provide Legal Aid Services_VERSION 2 Page 7 / MOJ Part 1-Provide Legal Aid Form_4jb.indd 7 26/10/11 5:21 PM

8 d) Maintenance of your service delivery systems Are your office management practices documented? eg practice manual Yes No How do you ensure that your office management practices are up to date? What research facilities / resources do you have access to? e) Indemnity insurance Are you a partner in a legal firm? Yes No Do you have indemnity insurance? Yes No If no Have you been refused indemnity insurance? Please give reason for refusal What system do you have in place to deal with negligence or other claims? f) Office administration Please provide contact details for your office manager or a person who can verify the information you have provided about your service delivery systems. Name Position Work address Work phone Business Application for Approval to Provide Legal Aid Services_VERSION 2 Page 8 / MOJ Part 1-Provide Legal Aid Form_4jb.indd 8 26/10/11 5:21 PM

9 Part 1 Section 4 Admission details and work experience history a) Admission Date of admission as a barrister and solicitor in New Zealand Date your first practising certificate was issued D D / M M / Y Y Y Y Date of admission if first admitted in overseas jurisdiction Country of admission Total years of practice in New Zealand (cumulative i.e. not necessarily uninterrupted) Total years of practice overseas (cumulative i.e. not necessarily uninterrupted) b) Relevant legal employment history (Start with the most recent and work back) Start date M M / Y Y End date M M / Y Y Position held / role description Employer Were you representing clients as a Barrister or Solicitor Yes No Did you hold a practising certificate? Yes No Start date M M / Y Y End date M M / Y Y Position held / role description Employer Were you representing clients as a Barrister or Solicitor Yes No Did you hold a practising certificate? Yes No Start date M M / Y Y End date M M / Y Y Position held / role description Employer Were you representing clients as a Barrister or Solicitor Yes No Did you hold a practising certificate? Yes No Start date M M / Y Y End date M M / Y Y Position held / role description Employer Were you representing clients as a Barrister or Solicitor Yes No Did you hold a practising certificate? Yes No Application for Approval to Provide Legal Aid Services_VERSION 2 Page 9 / MOJ Part 1-Provide Legal Aid Form_4jb.indd 9 26/10/11 5:21 PM

10 c) Publications you ve written (if any) Title of your article or other work Name of the journal or other publication Date D D / M M / Y Y Y Y Title of your article or other work Name of the journal or other publication Date D D / M M / Y Y Y Y Part 1 Section 5 Acknowledgement and Consent Privacy statement I accept that the Ministry of Justice needs this information to assess whether I meet the criteria for approval I accept that the Ministry of Justice may verify the information I have provided in this application I note that I have the right to access this information that the Ministry of Justice holds about me and ask for it to be corrected if I think it is incorrect. I have been advised that evaluative information gathered by Selection Committees is retained in an anonymous and summarised format I note that the information is retained for as long as the information is required taking into account the purpose for which it was obtained. Statutory declaration I solemnly and sincerely declare that the information I have provided in this application is accurate and complete. I consent to this information being used to assess whether I may be approved in the areas of law for which I have applied and for the functions associated with being an approved provider under the Legal Services Act Full name of applicant making this declaration Residential address of the applicant making this declaration Applicant s signature Declared at this day the month and year of D D / M M / Y Y Y Y Before me (Name or stamp of person authorised to take a statutory declaration) Authorised person s signature Designation Application for Approval to Provide Legal Aid Services_VERSION 2 Page 10 / MOJ Part 1-Provide Legal Aid Form_4jb.indd 10 26/10/11 5:21 PM

11 When you have completed this application form please send the original completed form and supporting documentation to: Provider and Community Contracts Legal Aid Ministry of Justice Level 3, The Vogel Centre, 19 Aitken Street, Wellington 6011 or SX10125, Wellington The Ministry retains the right to return your application to you if it considers that it is incomplete or not in the prescribed format. This does not mean that you have been declined approval. Application for Approval to Provide Legal Aid Services_VERSION 2 Page 11 / MOJ Part 1-Provide Legal Aid Form_4jb.indd 11 26/10/11 5:21 PM