UNITED STATES DISTRICT COURT District of Maine ______________________________ ______________________________ Plaintiff(s), vs. ______________________________ ______________________________ Defendant(s). ) ) ) ) ) ) ) ) ) Case No. _______________ CERTIFICATION FOR ADMISSION PRO HAC VICE I hereby request admission to the Bar of this Court Pro Hac Vice, in support of which I represent that the answers to the following questions are complete, true and correct: 1. Name: _________________________________________________________________ 2. State bar membership number(s):_____________________________________________ 3. Firm name, address and telephone number: _____________________________________________________________________________ _____________________________________________________________________________ 4. List state and federal courts or bar associations in which you are a member in good standing to practice law: _____________________________________________________________________________ _____________________________________________________________________________ 5. Name, address and telephone number of associated local counsel: _____________________________________________________________________________ _____________________________________________________________________________ 6. Have you been denied admission, disbarred, suspended from practice, reprimanded, denied “in good standing” status, or otherwise disciplined by any court, bar association, grievance committee or administrative body? Yes No 7. Have any proceedings, which could lead to any such disciplinary actions as described in question 6, been instituted against you by any such bodies? Yes No (You must attach a separate sheet with detailed explanations of Yes answers to Questions 6 or 7.) 8. Are you familiar with the Federal Rules of Evidence, the Federal Rules of Civil or Criminal Procedure (as applicable to this case) and the local rules of this Court? Yes No Dated: Signature of Local Counsel Dated: ___________________ _____________________________________________ Signature of Applicant American LegalNet, Inc. www.FormsWorkFlow.com