IN THE SUPREME COURT OF MISSOURI APPLICATION FOR LIMITED ADMISSION AS IN-HOUSE COUNSEL Applicant’s Name: 1. DOB: Telephone numbers and email address where you can be contacted about this application: Home: Office: Other: E-mail Address: 2. Mailing Address: Street Address: City: State: Zip: 3. Are you a graduate of a law school approved by the American Bar Association? 4. List every state or territory in which you are admitted to practice law and dates of admission: State: 5. Admitted Mo/Yr: State: NO Admitted Mo/Yr: State: YES Admitted Mo/Yr: I am or will be employed in Missouri as a lawyer exclusively for the employer listed below, which is: a corporation; an association; a business; or a governmental entity and the employer’s lawful business consists of activities other than the practice of law or the provision of legal services. EMPLOYER: Name o f Corpor ation, Assoc iation, Busine ss, or Entity Street Address City State Zip Teleph one: 6. Fax: Are there any pending disciplinary complaints or grievances filed with any disciplinary authority concerning your conduct as an attorney? YES NO 1 American LegalNet, Inc. www.FormsWorkflow.com 7. All applications and files are confidential. We will not discuss the status of your application with anyone without your authorization, including a secretary or administrative assistant who contacts our office on your behalf. List the name and phone number of anyone with whom you authorize us to discuss your application. CONTINUING APPLICATION I understand this Application for Limited Admission for In-House Counsel is a continuing application and must show correctly and fully the information herein sought during the time said application is pending before the Supreme Court of Missouri and the Board of Law Examiners. I incorporate into this application all statements made in the attached Application for a Character & Fitness Report executed by me. I will, therefore, not later than thirty (30) days after the happening of any such event notify the Board by filing an update to this application as to any change in respect to any matter regarding which information is herein sought, and as to any incident which may have any bearing upon any information sought. I hereby swear (or affirm) under penalty of perjury, that all statements herein were made by me and are true and complete. Dated / / . Signature of Applicant State of ) County of ) ) SS. this Subscribed and sworn before me, a Notary Public, within and for said county and state, day of , 20 . My commission expires: / / /. Notary Public 2 American LegalNet, Inc. www.FormsWorkflow.com AFFIDAVIT OF OFFICER, DIRECTOR OR GENERAL COUNSEL OF APPLICANT'S EMPLOYER State of ___________________ ) ) SS County of __________________) I, , being duly sworn state that I am an officer, director or general counsel of , the employer of , an applicant for limited admission to the Missouri Bar under the provisions of Rule 8.105; that said applicant is employed exclusively as a lawyer for said employer; and that the nature of the employment conforms to the requirements of Rule 8.105. Further, affiant states that said employer will notify the Supreme Court of Missouri, in writing, if applicant’s employment with the above employer ends. _______________________________________________ Signature of Affiant Subscribed and sworn to before me, a Notary Public, within and for said county and state, this_______________day of_____________________________20_____. My commission expires _________. ______________________________________________ Notary Public 3 American LegalNet, Inc. www.FormsWorkflow.com