For Official Use Only App# Bar Number# Attn: Pro Hac Vice Dept PO Box 53099 Phoenix, AZ 85072-3099 Phone: 602-340-7239 Application for Appearance Pro Hac Vice PART I: Applicant Information Name of Applicant: Firm/Company Name: Office Address: Fax: Telephone: Email Address: Residence Address: Title of cause or case where applicant seeks to appear: Docket Number: Court, Board, or Administrative Agency: Party on whose behalf applicant seeks to appear: Pursuant to Arizona Supreme Court Rule 38(i)(3), the applicant shall complete the information below: Courts to Which Applicant Has Been Admitted: Date of Admission: Bar Number: (Attach additional pages if needed) Applicant is a member in good standing in such courts. Applicant is not currently disbarred or suspended in any court. Applicant is / is not (select one) currently subject to any pending disciplinary proceeding or investigation by any court, agency or organization authorized to discipline attorneys at law. In the preceding three (3) years, applicant has filed applications to appear as counsel under AZ ST S.Ct., Rule 38(a) in the following: Title of Matter: Docket #: Court or Agency: App Granted? (Y/N) This case or cause is / is not (select one) a related or consolidated matter for which applicant has previously applied to appear pro hac vice in Arizona. If this matter is a related or consolidated with any previous application, Applicant certifies that he/she will review and comply with appropriate rules of procedure as required in the underlying cause. If applicable, please provide related or consolidated matter application or docket# Revised 01/15/09 American LegalNet, Inc. www.FormsWorkflow.com Page 2 PART II: Local Counsel Information Name of Arizona Local Counsel: State Bar of Arizona Number: Address: Telephone: Fax: Email Address: Local Counsel is a member in good standing. Local Counsel associating with a nonresident attorney in a particular cause shall accept joint responsibility with the nonresident attorney to the client, to opposing parties and counsel, and to court, board, or administrative agency in that particular cause. PART III: Parties and Certification Name(s) of each party in this cause and name and address of all counsel of record: Party: Counsel of Record: Address: Applicant is including with this application a nonrefundable application fee, payable to the State Bar of Arizona, in the amount of $460.00. Fifteen percent of the non-refundable application fee paid pursuant to this section shall be deposited into a civil legal services fund to be distributed by the Arizona Foundation for Legal Services and Education entirely to approved legal services organizations, as that term is defined in subparagraph (f) of this rule. Applicant is furnishing a certificate from the state bar or from the clerk of the highest admitting court of each state, territory, or insular possession of the United States in which the nonresident attorney has been admitted to practice law certifying the nonresident attorney's date of admission to such jurisdiction and the current status of the nonresident attorney's membership or eligibility to practice therein. The certificate furnished shall be no more than forty-five (45) days old. Applicant certifies the following: 1. Applicant shall be subject to the jurisdiction of the courts and agencies of the State of Arizona and to the State Bar of Arizona with respect to the law of this state governing the conduct of attorneys to the same extent as an active member of the State Bar of Arizona, as provided in Rule 46(b) Rules of the Supreme Court. 2. Applicant will review and comply with appropriate rules of procedure as required in the underlying cause. 3. Applicant understands and shall comply with the standards of conduct required of members of the State Bar of Arizona. Verification STATE OF ) County of ) ss. I, best of my knowledge and belief. , swear that all statements in the application are true, correct and complete to the Dated: Applicant’s Signature: SUBSCRIBED AND SWORN TO before me this day of , 20 , by . Name of Applicant Notary Public Revised 01/15/09 American LegalNet, Inc. www.FormsWorkflow.com