IN THE SUPREME COURT OF MISSOURI Application for Certificate to Practice Temporarily for Lawyers Applying for Admission to The Missouri Bar I, declare under penalty of perjury: (1) that I have applied for admission to practice law in Missouri under Rule 8.07, Rule 8.10 or Rule 8.105; (2) that I have not previously failed the Missouri bar examination; (3) that I am an active member in good standing of the highest court of a state or territory of the United States; (4) that I am not under suspension or disbarment by any court of record or the subject of any pending disciplinary complaints; (5) that I am not ineligible for admission under Rule 8.04; (6) that I will be supervised as provided in Rule 4-5.1 by the active Missouri licensed attorney whose name and bar enrollment number are shown below: Supervisi ng Attorne y’s Name MO Bar # (7) that attached to this application is a statement from the supervising lawyer agreeing to the specified supervision; (8) that I understand this application for a certificate to practice law in this state temporarily must be approved by the Court; (9) that if I am issued a certificate to practice law in this state temporarily, it will be valid for 12 months from the date it is issued, unless revoked before the expiration of 12 months; (10) that the certificate shall be revoked immediately without further action by the Court if I (1) Fail the bar examination, (2) Fail to take the bar examination when eligible to do so, (3) Am denied permission to take the bar examination or denied approval on character and fitness grounds (4) Am denied admission without examination or limited admission as in-house counsel and am not permitted to take the bar examination in lieu thereof; (5) No long meet the qualifications prescribed in Rule 8.06(a); (11) that I have thoroughly familiarized myself with and will abide by Supreme Court Rule 4, Rules of Professional Conduct; 1 American LegalNet, Inc. www.FormsWorkflow.com (12) that I acknowledge the jurisdiction of the Supreme Court of Missouri and Chief Disciplinary Counsel over my professional conduct. I hereby swear (or affirm) under penalty of perjury, that all statements herein were made by me and are true and complete. Dated this ___________ day of _______________________________ 20 __________. Signature of Applicant Subscribed and sworn to before me this _________ day of _________________________ 20______. _______________________________________ Notary Public [Seal or stamp must be affixed] 2 American LegalNet, Inc. www.FormsWorkflow.com In the Application of: (Applicant’s Name and Social Security Number) STATEMENT OF SUPERVISING ATTORNEY (Supervising Attorney’s Full Name) Missouri Bar N umber) I state that I am an active member in good standing of the Missouri Bar. If the above-named applicant is granted a certificate to practice law in Missouri temporarily pursuant to Rule 8.06, I agree to exercise supervisory responsibility for the applicant as provided in Rule 4-5.1 during the period that the certificate is valid. Signature of Supervising Attorney Street Address City, State, Zip Daytime Telephone (List Above Supervising Attorney’s Business Address and Daytime Telephone Number) 3 American LegalNet, Inc. www.FormsWorkflow.com