Attorney or Vendor * Attorney Vendor Personal Information First Name: * Middle Name: Last Name: * Bar Number: * Bar State: * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming List your current LAWD CJA appointed cases, if any: Primary Division: Alexandria Lake Charles Monroe Shreveport Lafayette Additional Divisions: Alexandria Lake Charles Monroe Shreveport Lafayette Phone Number: * XXX-XXX-XXXX Fax Number: XXX-XXX-XXXX Cell Number: XXX-XXX-XXXX Primary Email: * Your login and password will be sent to the email address entered above. You must enter a valid email address in order to obtain eVoucher access. Additional Email: If you would like a notice sent to another email address, in addition to your primary email address, please enter it in the field above. Firm/Company Billing Information - Mailing Address Firm/Company Name: * Address 1: * Address 2: City: * State: * - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Mailing Address Zip + 4: * By submitting this request form, the undersigned agrees to the following: Under the CJA eVoucher Program you will be filing CJA vouchers and related documents electronically with the U.S. District Court for the Western District of Louisiana. When using the CJA eVoucher Program, you must abide by the Federal Rules of Civil and Criminal Procedure, CJA Guidelines, the Local Rules, and any administrative orders and policies of the Western District of Louisiana. You have full responsibility to ensure your user information, including your billing information, is accurate. The combination of the username and password within the CJA eVoucher Program will serve as the signature of the attorney filing the voucher or documents under the aforereferenced rules and procedures. Therefore, you are responsible for protecting and securing this password against unauthorized use. If you have any reason to suspect that your password has been compromised, you are responsible for immediately notifying the Clerk of Court of the suspected breach of security. Agreement * No Yes I have read and agree with the Vendor Participation Agreement Statement. Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Attorney/Vendor/Participant Signature * ex. s/ John M. Doe
