IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT COUNTY, ILLINOIS ) ) ) ) ) ) ) vs. NO. ___________________ APPLICATION FOR ADMISSION OF COUNSEL PRO HAC VICE I, __________________________________, pursuant to Supreme Court Rule 707 and Rule 21.05 of the Local Rules of the Nineteenth Judicial Circuit, hereby request permission to appear and participate as an attorney at law in the above entitled cause, on behalf of ___________________________, a party in this cause. In support of this application, I ________________________________, being first duly sworn on oath state as follows: 1. I am a licensed attorney and counselor at law in the State of ______________________________, where I regularly practice law. My attorney registration number in that State is _______________________. 2. In addition, I am licensed to practice law in the States of ___________________________________, and am admitted to practice before the following federal courts ______ ________________________________________________________ ____. I have never been licensed to practice law in the State of Illinois or I was licensed to practice law in the State of Illinois from _____________________ to _____________________ (strike the inapplicable portion). 3. 4. I have practiced law for ______ years. I have made the following pro hac vice applications to the courts of the Case Number Case Title Granted or Denied (if denied, explain) State of Illinois. County 1 American LegalNet, Inc. www.USCourtForms.com 5. 6. I have never been suspended or disbarred by any court. The following disciplinary proceedings have been instituted against me (include title, number, jurisdiction involved, allegations and outcome): 7. I (will) (will not) retain an attorney licensed to practice law in the State of Illinois as local counsel. Local counsel (if applicable) is _____________________________ (name, address and registration number) __________________________________________________________________ _________________________________ 8. My qualifications to act as counsel in this case include _ 9. I am familiar with, and will abide by, the Illinois Code of Civil Procedure, Illinois Supreme Court Rules, and Local Rules of the Nineteenth Judicial Circuit. In particular, I am familiar with Supreme Court Rule 137. 10. I agree to immediately notify the Court and all counsel of record in the ___________________________________ Name event any information provided in this application changes or becomes inaccurate. ___________________________________ Firm name, if any Business Address Telephone ___________________________________ ___________________________________ Subscribed and Sworn to before me this ____ day of _______________, _____ _________________________________ _________________________________ Notary Public 2 American LegalNet, Inc. www.USCourtForms.com