Application Form Of Attorney For Admission To Practice Pro Hac

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IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Plaintiff(s)/Petitioner(s),

CASE NO:

vs.

Application of Attorney For Admission To Practice Pro Hac

Vice Pursuant to LRCiv 83.1(b)(2)

Defendant(s)/Respondent(s)

NOTICE: APPLICATION FEE REQUIRED!

, hereby apply to the Court under LRCiv 83.1(b)(2) for pro hac vice

admission to appear and practice in this action on behalf of

City and State of Principal Residence:

Firm Name:

Address:

Suite:

City:

State:

Zip:

Firm/Business Phone:

(

)

Firm Fax Phone:

(

)

E-mail Address:

I am admitted to practice before the following courts. (attach additional sheets if necessary)

TITLE OF COURT

DATE OF ADMISSION

IN GOOD STANDING?

Yes

No*

Yes

No*

Yes

No*

* Explain:

(An Original Certificate of Good Standing from a FEDERAL BAR in which an applicant has been adm itted dated no more than 45 days

prior to submission of this application is required.)

I have concurrently, or within 1 year of this application, made pro hac vice applications to this Court in the following actions (attach

additional sheets if necessary):

Case Number

Title of Action

Date Granted or Denied*

* Explain:

ALL APPLICANTS ARE REQUIRED TO ANSWER THE FOLLOWING QUESTIONS.

If you answer YES to either of the following questions, please explain all circumstances on a separate page.

Are you currently the subject of a disciplinary investigation or proceeding by any Bar or Court?

Yes

Have you ever been disbarred from practice in any Court?

Yes

I declare under penalty of perjury that the foregoing is true and correct; that I am not a resident of, nor am I regularly employed, engaged in business, professional

or other activities in the State of Arizona; and that I am not currently suspended, disbarred or subject to disciplinary proceedings in any court. I certify that I

have read and will ascribe to the Standards for Professional Conduct, will comply with the Rules of Practice of the United States District Court for the

District of Arizona (“Local Rules”), and will subscribe to receive court notices as required by LRCiv 83.1(c).

Date

Signature of Applicant

Fee Receipt #

(Rev. 04/12)