CJA eVoucher Access Form

This form shall be used to request access to the CJA eVoucher system.

* denotes a required field

Personal Information

First Name:

Middle Name:

Last Name:

Bar Number:

Bar State:

List your current MDFL CJA appointed cases, if any

Primary Division:

Additional Divisions:

Ft. Myers Jacksonville Ocala Orlando Tampa

Phone Number:

nnn-nnn-nnnn *

Fax Number:

nnn-nnn-nnnn

Primary E-mail:

Your login and password will be sent to the e-mail address entered above. You must enter a valid e-mail address in order to obtain eVoucher access.

Additional E-mail:

If you would like a notice sent to another e-mail address, in addition to your primary e-mail address, please enter it in the field above.

W-9 Form:

Please select your W-9 form as a PDF file in the field above.

Firm Information - Mailing Address

Firm Name:

Address 1:

Address 2:

City:

State:

Mailing Address Zip + 4

Please enter the number that appears below:

You will receive an email within two business days.

Date

Attorney/Participant Signature

Type your full name, prefixed with "s/", in the field above to acknowledge that you have read and understand the information in this document.