UNITED STATES DISTRICT COURT EASTERN DISTRICT OF LOUISIANA ATTORNEY REGISTRATION STATEMENT Pursuant to Local Rule 83.2.2 of the United States District Court for the Eastern District of Louisiana TITLE Mr. ___ Mrs. ___ Miss ___ Ms. ____ LA Bar No. _________ NAME __________________________________________________ (Last) (First) (Middle) FIRM NAME _____________________________________________ OFFICE ADDRESS RESIDENCE ADDRESS ___________________________________ ___________________________________ __________________________________ ___________________________________ BUSINESS TELEPHONE NUMBER FAX NUMBER _____________________ ___________________________________ List below the Bars of all states, territories, districts, commonwealths or possessions or other courts of the United States to which you are admitted to and the dates of such admissions: Bars Dates ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ _______________ Date ____________________________ Signature NOTE: A Supplemental statement of any changes in the foregoing information shall be filed within 30 days of such change. Rev 4/11 American LegalNet, Inc. www.FormsWorkFlow.com