APPENDIX X IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA : : : : : ORDER AND NOW, this Day of , , it is hereby , Esquire, to practice in this CIVIL ACTION v. NO. ORDERED that the application of court pursuant to Local Rule of Civil Procedure 83.5.2(b) is GRANTED. DENIED. J. American LegalNet, Inc. www.FormsWorkFlow.com IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA Civil Action No# APPLICATION FORM FOR THOSE ATTORNEYS SEEKING TO PRACTICE IN THIS COURT PURSUANT TO LOCAL RULE OF CIVIL PROCEDURE 83.5.2(b) I. APPLICANT'S STATEMENT I, the undersigned, am an attorney who is not currently admitted to either the bar of this court or the bar of the Supreme Court of Pennsylvania, and I hereby apply for admission to practice in this court , for the $40.00 admission pursuant to Local Rule of Civil Procedure 83.5.2(b), and am submitting a check, number fee. A. I state that I am currently admitted to practice in the following state jurisdictions: (Admission date) (Admission date) (Admission date) (Attorney Identification Number) (Attorney Identification Number) (Attorney Identification Number) (State where admitted) (State where admitted) (State where admitted) B. I state that I am currently admitted to practice in the following federal jurisdictions: (Admission date) (Admission date) (Admission date) (Attorney Identification Number) (Attorney Identification Number) (Attorney Identification Number) (Court where admitted) (Court where admitted) (Court where admitted) C. I state that I am at present a member of the aforesaid bars in good standing, and that I will demean myself as an attorney of this court uprightly and according to law, and that I will support and defend the Constitution of the United States. I am entering my appearance for (Applicant's Signature) (Date) APPLICANT'S FIRM NAME / ADDRESS / TELEPHONE NUMBER: Sworn and subscribed before me this Day of Notary Public , 200 10/04 American LegalNet, Inc. www.FormsWorkFlow.com II. SPONSOR'S STATEMENT, MOTION AND CERTIFICATE OF SERVICE The undersigned member of the bar of the United States District Court for the Eastern District of Pennsylvania hereby moves for the admission of to practice in said court pursuant to Local Rule of Civil Procedure 83.5.2(b), and certify that I know (or after reasonable inquiry believe) that the applicant is a member in good standing of the abovereferenced state and federal courts and that the applicant's private and personal character is good. I certify that this application form was on this date mailed, with postage prepaid, to all interested counsel. Sponsor's Name Sponsor's Signature Admission date Attorney Identification No. SPONSOR'S OFFICE ADDRESS AND TELEPHONE NUMBER: Sworn and subscribed before me this Day of Notary Public , 200 American LegalNet, Inc. www.FormsWorkFlow.com IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF PENNSYLVANIA : : : : : CIVIL ACTION v. NO. CERTIFICATE OF SERVICE I declare under penalty of perjury that a copy of the application of Esquire, to practice in this court pursuant to Local Rule of Civil Procedure 83.5.2(b) and the relevant proposed Order which, if granted, would permit such practice in this court was Signature of Attorney Name of Attorney Name of Moving Party Date American LegalNet, Inc. www.FormsWorkFlow.com