United States District Court Northern District of Indiana Stephen R. Ludwig, Clerk ATTORNEY ADMISSION APPLICATION ELIGIBILITY Any attorney admitted to practice by the Supreme Court of the United States or the highest court of any state [L.R. 83.5(b)]. PLEASE READ COMPLETELY GENERAL INFORMATION Fee: $160.00 - cash, money order or check (payable to “Clerk, U.S. District Court”). Application: 1. An application form follows these instructions. 2. You will need a movant, in good standing, who is a member of the Bar of this Court. The movant will sign and date the form which personally assures the Court of the Applicant’s private and professional character. 3. Mail your application and check or money order to: Clerk, U.S. District Court 102 Robert A. Grant Courthouse 204 South Main Street South Bend, IN 46601 4. Your certificate will be sent by mail. American LegalNet, Inc. www.FormsWorkFlow.com Print Form UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF INDIANA APPLICATION FOR ADMISSION TO PRACTICE Prefix (check one) Mr. Ms. Mrs. Last Name: First Name: Middle Initial: Generation (Sr, Jr, etc) Firm Name: Street Address: Suite/Room No.: City: State: Zip: Office Telephone No.: Zip + 4: Fax No.: Attorney Registration No.: State: E-Mail Address: EDUCATION: College: Degree: Law School: Year Completed: Year Graduated: Other Post-Graduate Schooling: Currently Admitted to Practice Before: U.S. Supreme Court 7th Circuit Court of Appeals Indiana Supreme Court Other Please list below all other courts to which you have been admitted to practice, excluding Pro Hac Vice admissions. Note: In accordance with Local Rule 83.5 you must attach a current Certificate of Good Standing (less than 60 days old) from the appropriate agency of each state in which you are admitted to practice. Have you ever been subjected to public discipline by any court of the United States, the District of Columbia, or by a court of any State, Territory, commonwealth or possession of the United States? Yes (If yes, please attach an explanation) No American LegalNet, Inc. www.FormsWorkFlow.com APPOINTMENTS UNDER THE CRIMINAL JUSTICE ACT AND THE CIVIL RIGHTS ACT: If you are willing to represent defendants determined to be eligible for representation under the Criminal Justice Act please contact the CJA Panel Administrator of the Community Defenders Office at 219-937-8020. If you are willing to be appointed to represent complainants in Civil Rights cases, check all types of cases that apply. Employment Discrimination (e.g. Title VII of the Civil Rights Act of 1964, Americans with Disabilities Act, 42 U.S.C. § 12112(d)(2) Non-Prisoner Civil Rights (42 U.S.C. § 1983) Prisoner Civil Rights (42 U.S.C. § 1983) Applicant: I, , do solemnly swear or affirm that: I am a member in good standing of the bar of every jurisdiction to which I am admitted to practice. I will support and defend the Constitution and laws of the United States of America against all enemies, foreign and domestic; that I will bear true faith and allegiance to the same; that I take this obligation freely, without any mental reservation or purpose of evasion; and that I will demean myself as attorney, proctor and solicitor of the United States District Court for the Northern District of Indiana uprightly and according to law, so help me God. I have read and will abide by the Local Rules of the United States District Court for the Northern District of Indiana, including Appendix B: Standards for Professional Conduct Within the Seventh Federal Judicial Circuit. I declare under penalty of perjury that the statements in this application are true and correct. Dated: Signature of Applicant Movant: I, , a member in good standing of the bar of this Court hereby certify that the above information is correct to the best of my knowledge and I now personally assure the Court that the Applicant's private and professional character is good and do now move for the admission of the application. Dated: Signature of Movant Movant's Attorney Registration No. State Registered American LegalNet, Inc. www.FormsWorkFlow.com Considered and approved. SO ORDERED. Dated: Judge, U.S. District Court Form Adopted and Approved by General Order 2009-2 (revised September 2010) American LegalNet, Inc. www.FormsWorkFlow.com