This form shall be used to request access to the CJA eVoucher system as a vendor. * denotes a required field PERSONAL INFORMATION First Name * Middle Name Last Name * List your current FLSD CJA Appointed Cases, if any Primary Division * - Select -MiamiFort LauderdaleWest Palm BeachFort PierceKey West Specialties AccountantBallistics ExpertCALR(Westlaw, Lexis, etc)Chemist, ToxicologistComputer (Hardware, Software, Systems)Forensics ExpertCourt ReporterDocuments ExaminerDuplication ServicesFingerprint AnalystHair, Fiber ExpertInterpreter TranslatorInvestigatorJury ConsultantLegal Analyst/ConsultantLitigation Support ServicesMitigation SpecialistOtherOther Medical ExpertParalegal ServicesPathologist, Medical ExaminerPolygraph ExaminerPsychiatristPsychologistVoice, Audio AnalystWeapons Firearms Explosive Expert Please upload your W-9 form as a PDF file Files must be less than 2 MB.Allowed file types: gif jpg jpeg png pdf. Phone Number * Fax Number Primary Email * 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. BILLING INFORMATION - Mailing Address Company Name * Address 1 * Address 2 City * State * - Select -FLORIDAALABAMAALASKAARIZONAARKANSASCALIFORNIACOLORADOCONNECTICUTDELAWAREDISTRICT OF COLUMBIAGEORGIAHAWAIIIDAHOILLINOISINDIANAIOWAKANSASKENTUCKYLOUISIANAMAINEMARYLANDMASSACHUSETTSMICHIGANMINNESOTAMISSISSIPPIMISSOURIMONTANANEBRASKANEVADANEW HAMPSHIRENEW JERSEYNEW MEXICONEW YORKNORTH CAROLINANORTH DAKOTAOHIOOKLAHOMAOREGONPENNSYLVANIAPUERTO RICORHODE ISLANDSOUTH CAROLINASOUTH DAKOTATENNESSEETEXASUTAHVERMONTVIRGINIAWASHINGTONWEST VIRGINIAWISCONSINWYOMING Zip Code * 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 Southern District of Florida. 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 United States District Court of the Southern District of Florida. 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 vendor filing the voucher or documents under the afore referenced 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. Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20162017201820192020 Vendor/Participant Signature s/ * Type your full name, prefixed with "s/", in the field above to acknowledge that you have read and understand the information in this document.