APPLICATION FOR PERMISSION FOR ATTORNEY TO APPEAR PRO HAC VICE BEFORE A MUNICIPAL OR STATE AGENCY, COMMISSION, BOARD OR TRIBUNAL JD-CL-142 New 1-17 P.B. 2-16 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Instructions 1. Complete this Application and attach completed Affidavit of Attorney Seeking Permission to Appear Pro Hac Vice (JD-CL-143). 2. File as new case using Case Type M 88 and pay pro hac vice fee electronically. 3. Enter the Out-of-State Attorney's name as the plaintiff and "In Re: Pro Hac Vice Application" as the defendant (select person and use last name field). Judicial district Name of Out-of-State attorney Address of court The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. ADA NOTICE In Re Pro Hac Vice Application Name of agency, commission, board or tribunal Case number Pursuant to Section 2-16 of the Practice Book, the undersigned, a member in good standing of the Connecticut bar, moves this Court to permit Out-of-State Attorney Applicant , an attorney who is not a member of the bar of the State of Connecticut, to appear pro hac vice on behalf of (client name) in a proceeding before (name of agency, commission, board, or tribunal) In support of this motion, the undersigned represents the following: The undersigned is a Connecticut attorney with a law office located at: The Out-of-State Attorney Applicant has a law office located at: The Out-of-State Attorney Applicant is a member in good standing of the bar(s) of: Good cause exists to permit the Out-of-State Attorney Applicant to represent the client named above in the proceeding before (name of agency, commission, board, or tribunal) because: The undersigned represents that s/he will, unless excused by the judicial authority, a. Be present at all proceedings, including depositions, b. Sign all pleadings, briefs or other papers filed with the court. c. Assume full responsibility for any such filings and for the conduct of the cause or proceeding and of the attorney to whom such privilege is accorded. Certification (Required for all matters currently pending before any agency, commission, board, or tribunal) I certify that a copy of this document was or will immediately be mailed or delivered electronically or non-electronically on (date) to all agencies, commissions, boards, tribunals, attorneys and self-represented parties of record and that written consent for electronic delivery was received from all entities, attorneys and self-represented parties receiving electronic delivery. Name and address of each party and attorney that copy was mailed or delivered to* *If necessary, attach additional sheet or sheets with name and address which the copy was mailed or delivered to. Signed (Signature of filer) Print or type name of person signing Date signed Telephone number u Mailing address (Number, street, town, state and zip code) American LegalNet, Inc. www.FormsWorkFlow.com