UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT PETITION FOR ADMISSION (FORM MUST BE TYPED) I, , do hereby petition the Honorable Judges of the United States District Court for the District of Connecticut for admission to the Bar of the Court, and I respectfully submit to the Clerk of Court the following information required by Local Rule 83.1.(b): 1. I reside at: 2. My office address is: Name of Firm: Address: Office Phone Number: Email Address: FAX Number: 3. I was admitted to practice before the Bar of the following courts (list all state and federal courts and dates of admission): Please include a current (dated within the past six months) certificate of good standing from each state bar listed. 4. I was previously admitted as a pro hac vice attorney in the District of Connecticut. My assigned pro hac vice number is: phv . 5. I received my undergraduate degree from in (year) , with a degree in I received my degree of J.D. or LL.B from in (year) . I received my degree of LL.M. from in (year) . 6. I have been engaged in the general practice of law in (name the state or district): from (date): to the present time. 7. I have carefully studied the jurisdictional provisions of Title 28 of the United States Code, the Federal Rules of Civil Procedure, the Federal Rules of Criminal Procedure, and the Local Rules of the United States District Court for the District of Connecticut. Revised 11/28/16 American LegalNet, Inc. www.FormsWorkFlow.com 8. I have attached to this petition certificates from two members of the Bar of the United States District Court for the District of Connecticut, stating the following: � � � � � � where and when the sponsor was admitted to practice in this Court; that the sponsor has known the petitioner in a professional legal capacity for at least six months; that the petitioner has good professional character; that the petitioner is experienced at the bar; how long and under what circumstances the sponsor has known the petitioner's professional character and experience as an attorney; and that the sponsor knows of no fact which would call into question the integrity or character of the petitioner. 9. I enclose a $225.00 check, payable to the Clerk, U. S. District Court. Dated at (city and state) of , this , 20 . day Signature of Applicant Typed Name of Applicant CERTIFICATE OF THE CLERK The Clerk, or her designee of the United States District Court for the District of Connecticut, hereby certifies that I have received and examined the petition for admission from the applicant and find it to be in full compliance with the requirements of the Local Rules. Accordingly, the petition is hereby approved and filed. Dated at Hartford, Connecticut, this 20 . day of , Clerk, U.S. District Court By Deputy Clerk Revised 11/28/16 American LegalNet, Inc. www.FormsWorkFlow.com ADDENDUM TO PETITION FOR ADMISSION TO THE BAR OF THE UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT AFFIDAVIT (FORM MUST BE TYPED) NAME OF APPLICANT Have you ever been denied admission to, been disciplined by, resigned from, surrendered your license to practice before, or withdrawn an application for admission to practice while facing a disciplinary complaint before this Court or any other Court? _____ No _____ Yes If your answer is yes, please explain: Do you have any pending disciplinary complaint(s) as to which a finding has been made that such complaint(s) should proceed to a hearing? _____ No _____ Yes If your answer is yes, please explain: Signature of Applicant Sworn and subscribed before me this 20 . day of , Notary Public/Commissioner of the State Revised 11/28/16 American LegalNet, Inc. www.FormsWorkFlow.com