APPLICATION TO PROCEED PRO HAC VICE BEFORE THE UNITED STATES COURT OF APPEALS FOR VETERANS CLAIMS IN THE CASE OF _______________________________DOCKET NO. ______________ Court Rule 46(b)(1)(F): "On motion and a showing of good cause, and submission of a completed application, the Court may permit any attorney or non-attorney practitioner not admitted to practice before the Court, or any other person in exceptional circumstances, to appear on behalf of a party or amicus curiae for the purposes of a particular case. Whenever a person makes an appearance under this subsection, the person will be deemed to have conferred disciplinary jurisdiction upon the Court for any alleged misconduct in the course of, in the preparation for, or in connection with any proceeding in that case. Each attorney and non-attorney practitioner generally is limited to one appearance under this subsection. Except as permitted by the Court, any subsequent appearances shall be made under Rule 46(a) (1) (Admission of Attorneys to Bar of Court) or (a)(2) (Admission of Non-Attorneys to Practice)." 1. Attorney's Name: (Mr.)(Ms.)_____________________________________________________ Date of Birth: ________________________________________ 2. Business Mailing Address:_______________________________________________ _______________________________________________ _______________________________________________ E-mail Address:___________________________________________ 3. Telephone Numbers: (Office)________________________(fax)_________________________ 4. Have you ever been suspended for misconduct or disbarred from the practice of law in any jurisdiction, or are you pending action as to your conduct or fitness to practice law which could result in public discipline? _______If yes, explain in full (including dates) on continuation sheet. 5. Have you ever had your right to practice in any jurisdiction or before any federal, state, or municipal department, bureau, commission, office, or agency qualified, terminated, or withdrawn, or has any such entity ever imposed public discipline on you, or is any such action pending? ______If yes, explain in full (including dates) on continuation sheet. 6. State all courts in which you are currently admitted: COURT BAR NO. DATE OF ADMISSION _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _____________________________________________________________________________________________ FORM 46C (9/11) Page 1 American LegalNet, Inc. www.FormsWorkFlow.com 7. Please provide your statement of good cause required for permission to practice pro hac vice: OATH (AFFIRMATION) I,_________________________________, solemnly swear (or affirm) that I am an attorney at law, in good standing in the Courts listed above and that I will conduct myself as an attorney and counselor of this Court, uprightly and according to law; and that I will support the Constitution of the United States. I certify under penalty of perjury that the foregoing is true and correct. (28 U.S.C.§ 1746) _______________________________ (Signature of Applicant) Date ______________________ MOTION GRANTED: _________________________ SIGNATURE ____________ DATE ___________________________ APPROVING OFFICIAL FORM 46C (9/11) Page 2 American LegalNet, Inc. www.FormsWorkFlow.com