United States District Court Northern District of Indiana Stephen R. Ludwig, Clerk PRO HAC VICE MOTION ADMISSION APPLICATION ELIGIBILITY Any attorney not a member of the bar of this court [L.R. 83.5(c)]. PLEASE READ COMPLETELY GENERAL INFORMATION Fee: $80.00 - cash, money order or check (payable to “Clerk, U.S. District Court”). Application: 1. A motion form follows these instructions. 2. Mail the completed motion and check or money order to: Clerk, U.S. District Court 102 Robert A. Grant Courthouse 204 South Main Street South Bend, IN 46601 3. The motion is for Clerk’s office use only and will not be placed in the Court file. American LegalNet, Inc. www.FormsWorkFlow.com Print Form UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF INDIANA v. Cause No. MOTION FOR ADMISSION TO PRACTICE PRO HAC VICE ON BEHALF OF Party(s) Represented Prefix (check one) Mr. Ms. Last Name: Mrs. 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 American LegalNet, Inc. to practice. www.FormsWorkFlow.com Have you ever been subjected to public discipline by any court of the United States of 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) Applicant: I, No , 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 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 Considered and approved. SO ORDERED. Dated: Judge, U. S. District Court Form Adopted and Approved by General Order 2009-2 American LegalNet, Inc. www.FormsWorkFlow.com