KENTUCKY BAR ASSOCIATION OUT-OF-STATE CERTIFICATION REQUEST FORM PLEASE PROVIDE THIS OFFICE WITH THE FOLLOWING INFORMATION: NAME: (PLEASE PRINT) DATE OF BIRTH:____________________ ADDRESS TO BE USED FOR KBA RECORDS: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ TELEPHONE NUMBER: (Please indicate if this is a business or home telephone number) ____________________________________ Home Business FAX NUMBER: ______________________ E-MAIL ADDRESS: _____________________________________ STATE BARS OF WHICH YOU ARE A MEMBER IN GOOD STANDING: (Please include membership number) __________________________________________________________________________________ KY COURT AND CASE NUMBER FOR WHICH YOU SEEK CERTIFICATION: __________________________________________________________________________________ KENTUCKY CO-COUNSEL / BAR #: ___________________________________________________ / _____________ (If the case number and/or Kentucky Co-Counsel are not known at this time, please forward as soon as available to: KY Bar Association, Attn: Accounting Department, 514 W Main St, Frankfort, KY 40601) Since January 1, 2005, have you practiced a case in Kentucky under SCR 3.030? YES NO SCR 3.030 Membership, practice by nonmembers and classes of membership (2) A person admitted to practice in another state, but not in this state, shall be permitted to practice a case in this state only if that attorney subjects himself or herself to the jurisdiction and rules of the court governing professional conduct, pays a per case fee of $100.00 to the Kentucky Bar Association and engages a member of the association as co-counsel, whose presence shall be necessary at all trials and at other times when required by the court. No motion for permission to practice in any state court in this jurisdiction shall be granted without submission to the admitting court of a certification from the Kentucky Bar Association of receipt of this fee. I have read and agree to comply with the requirements set forth in SCR 3.030(2), including submitting to the Rules of Professional Conduct of The Kentucky Supreme Court. I certify by signing this form that I am a member in good standing in my state(s) of licensure, and that the information provided by me on this form is true and correct. Notary Seal: SIGNATURE STATE OF_________________________________________) COUNTY OF__________________________) Acknowledged, subscribed & sworn to by___________________________________________________, who personally appeared before me on the ________ day of _________________________ , 20_____. NOTARY PUBLIC My Commission expires:_______________________ RETURN FORM TO: KENTUCKY BAR ASSOCIATION ATTN: MEMBERSHIP DEPARTMENT 514 W MAIN ST FRANKFORT KY 40601-1883 Phone (502)564-3795 American LegalNet, Inc. www.USCourtForms.com