):Name of agencyAddressCity State ZipCountry ProvinceSAMPLEDate of final dispositionDispositionDetailed explanationAttach a copy of the administrative record.STANDARD NCBE Form 3ARevised 12/15/2014 23, To be used with Question 23 FORM 4 / RECORD OF BANKRUPTCY OR INSOLVENCYName Middle Last Suffix Social Security Number FirstDate bankruptcy filed State ZipComplete title of action ProvinceCourt file numberName and complete address of court involved: Name of court Address City CountryDebts discharged: Account Number Amount Discharged Credit GrantorSAMPLEDate of final dispositionDispositionWere any adversary proceedings instituted? Your browser will redirect to your requested content shortly. A photocopy of this form isacceptable for purposes of obtaining this information.I hereby release, discharge, and exonerate the National Conference of Bar Examiners, its agents and representatives,the admitting authority, its agents and representatives, and the above named provider, its agents and representativesso furnishing information from any and all liability of every nature and kind arising out of the furnishing orinspection of any documents, records, and other information, or out of the investigation made by the NationalConference of Bar Examiners or by the admitting authority.I am not required to sign this authorization in order to receive treatment from the above provider. Please indicate the degree received or expected to be received or enter “No Degree” if you did not receive a degree. ����c-X��qȐ�~q=0 ݢ� □ Yes □ NoB. Please enable Cookies and reload the page. Were you administratively discharged? The records, however, will not include information relatingto any juvenile offense.I authorize the National Personnel Records Center in St. Louis, MO, or other custodian of my military record torelease to NCBE information or photocopies from my military record.I hereby release, discharge, and exonerate NCBE, its agents and representatives, the admitting authority of the abovejurisdiction, its agents and representatives, and any person so furnishing information from any and all liability ofevery nature and kind arising out of the furnishing or inspection of such documents, records, and other information,or the investigation made by NCBE or by the admitting authority.Signature of Applicant DateSTATE/DISTRICT OF______________________________COUNTY/PARISH OF______________________________Subscribed and sworn to or affirmed before me this dayof , Month YearSignature of Notary PublicMy commission expiresSeal or stamp must be affixed to each original. )STANDARD NCBE 3Revised 12/15/2014, EDUCATION INFORMATION4. *Yes No 2. *Applicants with foreign credentials (education or bar admission) are processed under Category IV or Category V(c) —see Fee Categories and Descriptions above.Check with the jurisdiction to which you are applying to determine if you should remit the fee directly to NCBE. endstream endobj 2079 0 obj <. If you provide a business address, please include the names of both the reference and the business. endstream endobj startxref List every permanent or temporary physical address where you have resided for a period of one month or longer in reverse chronological order: ● If you have submitted an application for bar admission or to pre-register as a law student with a bar admitting authority, or have been admitted, licensed, or authorized to practice law, provide your residency information for the last ten years or since you were first admitted, licensed, or authorized to practice law, whichever period of time is longer.
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