APPLICATION FOR ATTORNEY ADMISSION First Name: Last Name: Email Address: Firm Name (if applicable): Address: Middle Name (or initial): SS #: - City: Phone: State: Fax: Zip Code: I have complied with all applicable provisions of Local Rule 83.1 and have been admitted to practice in and am now in good standing before the following named courts: My Sponsor is . (Attorney Signature) COURT USE ONLY Place of Admission: Burlington Brattleboro Rutland Date of Admission: Judge: CR Receipt #: WKS JGM JMC Rule Book: (Proceed to Attached Addendum) L.R. 83.1 Compliance: ________________________ American LegalNet, Inc. www.FormsWorkFlow.com ADDENDUM TO APPLICATION FOR ADMISSION Name: (First) (Middle) (Last) (1) I am willing to be contacted to represent indigent plaintiffs in civil cases: Yes No If Yes, type of cases preferred: Prisoner - Conditions of Confinement Prisoner - Habeas Corpus Employment Discrimination Social Security Other (please specify): (2) I am willing to represent indigent parties in bankruptcy-related matters: Yes No (3) I would like to be considered for admission to the Court's standing Criminal Justice Act (CJA) Panel. Yes No (Note: separate requirements as per CJA Plan) (Rev. 01/2014) American LegalNet, Inc. www.FormsWorkFlow.com