UNITED STATES DISTRICT COURT FOR THE DISTRICT OF ARIZONA APPLICATION OF ATTORNEY FOR ADMISSION TO PRACTICE 1) IN THE MATTER OF THE APPLICATION FOR: (Last) (First) (Middle) TO THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF ARIZONA: Pursuant to the requirements of LRCiv 83.1 of the above entitled Court, I respectfully make application for admission to practice as an attorney, counselor, and solicitor in said Court. LAST NAME: FIRST NAME: PLACE OF BIRTH: CITY OF PRINCIPAL RESIDENCE: FIRM NAME: ADDRESS: CITY: FIRM/BUSINESS PHONE: ( ) STATE: ZIP: SUITE: MIDDLE: DATE OF BIRTH: STATE: SR/JR/III **************************************************************************************************************** 2) ARIZONA STATE BAR INFORMATION (a) AZ STATE BAR ADMISSION DATE: (b) AZ BAR NUMBER: **************************************************************************************************************** 3) ALL APPLICANTS ARE REQUIRED TO ANSWER ALL PARTS OF THIS SECTION. I have been admitted to practice in the following STATE/FEDERAL/CIRCUIT Courts of last resort (If more space is needed or you answer NO to "Member in Good Standing" or INACTIVE to "Current Status," you are required to disclose all relevant information on a separate page.): COURT NAME ADMISSION DATE MEMBER IN GOOD STANDING? Yes Yes Yes Yes Yes No No No No No ACTIVE OR INACTIVE? Active Active Active Active Active Inactive Inactive Inactive Inactive Inactive RETURN COMPLETED APPLICATION TO THE APPROPRIATE CLERK'S OFFICE WHERE YOU WISH TO BE ADMITTED: CLERK, US DISTRICT COURT DISTRICT OF ARIZONA 401 W Washington St SPC 1 Phoenix, AZ 85003-2118 OR CLERK, US DISTRICT COURT DISTRICT OF ARIZONA 405 W Congress St Tucson, AZ 85701 American LegalNet, Inc. www.FormsWorkFlow.com UNITED STATES DISTRICT COURT FOR THE DISTRICT OF ARIZONA Application For Admission to Practice 4) ALL APPLICANTS ARE REQUIRED TO ANSWER THE FOLLOWING QUESTIONS. If you answer YES to either of the following questions, please explain all circumstances on a separate page Are you currently the subject of a disciplinary investigation or proceeding by any Bar or Court? Yes No Have you ever been disbarred from practice in any Court? Yes No **************************************************************************************************************** Approx. Date of Last Appearance 5) I have PRACTICED in the following Courts: **************************************************************************************************************** 6) CERTIFICATE OF SPONSOR I, as an active member in good standing of the Arizona State Bar and the Bar of this Court, do hereby certify that , is a person of good moral character and professional standing. Signature of Sponsoring Attorney Typed/Printed Full Name and Address of Sponsoring Attorney Arizona Bar Number Date **************************************************************************************************************** 7) * * OATH UPON ADMISSION AND STANDARDS FOR PROFESSIONAL CONDUCT * * UNITED STATES OF AMERICA District of Arizona , solemnly swear (or affirm) that I will support the Constitution of the I, United States; that I will bear true faith and allegiance to the Government of the United States; that I will maintain the respect due to courts of justice and judicial officers; and that I will demean myself as an attorney, counselor, and solicitor of this Court uprightly. So Help Me God. My signature below indicates my confirmation to uphold the oath upon admission and that I have read and will ascribe to the Standards for Professional Conduct as adopted by the US District Court for the District of Arizona, and that the information I have provided on this application is true and accurate to the best of my knowledge. I further certify that I will comply with the Rules of Practice of the United States District Court for the District of Arizona ("Local Rules") and will subscribe to receive court notices as required by LRCiv 83.1(c). Signature of Applicant **************************************************************************************************************** 8) The above-named attorney is admitted to the bar of this Court this day of , 20 . BRIAN D. KARTH, DISTRICT COURT EXECUTIVE/CLERK OF COURT __________________________________________________________ Deputy Clerk (Rev. 03-12) American LegalNet, Inc. www.FormsWorkFlow.com