UNITED STATES DISTRICT COURT WESTERN DISTRICT OF NEW YORK IN THE MATTER OF THE APPLICATION OF _____________________________________________ PETITION (Name) TO BE ADMITTED TO PRACTICE AS AN ATTORNEY TO THE HONORABLE JUDGE ______________________________________ OF THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF NEW YORK: _____________________________________________________, petitioner herein, respectfully states: 1. That petitioner resides at: _____________________________________________________________________________ and has an office for the practice of law at: __________________________________________________________________ _____________________________________________________________________________________________________ 2. That petitioner attended the following educational institutions and received the following degrees: _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 3. Please complete either (a) or (b): (a) That petitioner was admitted to practice by the Appellate Division of the Supreme Court, ______ Department of the State of New York on the ____ day of ____________, ______. (b) That petitioner was admitted to practice in the United States District Court of the ____________ District of ____________ on the ______ day of ____________, _____, and is a member of the bar of the State in which that district court is located and in which the petitioner maintains an office for the practice of law, and said District Court by its rules extends a corresponding privilege of admission to members in good standing of the bar of the Western District of New York. 4. Petitioner is admitted to the following courts: ______________________________________________________________ _____________________________________________________________________________________________________ 5. Since such admission(s), petitioner has practiced in the following Courts: ________________________________________ _____________________________________________________________________________________________________ and has been involved in the following professional activities: ___________________________________________________ _____________________________________________________________________________________________________ 6. That Petitioner has never been held in contempt of court, or censured in a disciplinary proceeding, suspended or disbarred by any court or admonished by any disciplinary committee of the organized bar, nor is the subject of any pending complaint before any court: (Note: if petitioner cannot swear to this statement, see Local Rules, which detail the additional statement required of petitioner.) 7. That petitioner has read and is familiar with the provisions of Title 28 of the United States Code which pertain to jurisdiction of and venue in a United States District Court, the Federal Rules of Civil and Criminal Procedure, the Federal Rules of Evidence, the Local Rules of Practice for the United States District Court for the Western District of New York, the Code of Professional Responsibility as adopted by the Appellate Division of the State of New York and as interpreted and applied by the United States Supreme Court, the United States Court of Appeals for the Second Circuit, and this Court. WHEREFORE, the petitioner respectfully requests to be admitted as an attorney in the United States District Court for the Western District of New York. I verify under penalty of perjury that the foregoing is true and correct. _________________________________________________ (Signature of Petitioner) Sworn to before me this ____ day of ______________, ________ _________________________________________ Notary Public rev. 1999 American LegalNet, Inc. www.USCourtForms.com