NEBRASKA SUPREME COURT IN-HOUSE COUNSEL REGISTRATION AND/OR RENEWAL APPLICATION I, _________________________________________________, request to be certified as in-house counsel in the State of Nebraska, pursuant to Neb. Ct. R. �� 3-1201 to 3-1204. Check one: Initial Registration ($700) ______ Annual Renewal ($345) ______ Name and Nebraska address of corporation/entity employer: ________________________________________________ ________________________________________________ ________________________________________________ Nebraska telephone number of corporation or entity: __________________________________________ I declare, under penalty of perjury, that: 1. I am employed as in-house counsel for the above-named corporation/entity, and my employment conforms to the requirements of Neb. Ct. R. � 3-1201. 2. I am admitted to practice law in the following jurisdiction(s): _____________________________ ______________________________________________________________, and I am a member in good standing in the above-named jurisdiction(s). 3. I acknowledge that I am subject to the Rules of the Nebraska Supreme Court, including the rules for Registration of In-House Counsel, Neb. Ct. R. �� 3-1201 to 3-1204; and Rules of Professional Conduct, Neb. Ct. R. of Prof. Cond. �� 3-501.0 to 3-508.5. 4. I have attached the documentation required by Neb. Ct. R. � 3-1202 and the requisite fee payable to the Nebraska Supreme Court. 5. I acknowledge that any change in status of my license to practice law in any jurisdiction in which I am licensed to practice law or any change in status of my employment may automatically terminate my registration as in-house counsel in the State of Nebraska. 6. I will immediately inform the Counsel for Discipline of the Nebraska Supreme Court in writing of any disciplinary action commenced against me or sanction imposed in any jurisdiction in which I am licensed to practice law. Page 1 of 2 In-House Counsel Registration and/or Renewal Application Ch3Art12App1 Ammended 1/2012 Required pursuant to Neb. Ct. R. � 3-1202(A) Appendix 1 (Neb. Ct. R. � Chapter 3, Article 12) American LegalNet, Inc. www.FormsWorkFlow.com Full Legal Name: Mailing Address: Telephone Number: E-mail Address: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ Signature: _______________________________________ ) ) SS ) Date: _______________ State of Nebraska County of _____________________ Subscribed and sworn to before me on __________________________ Notary Public: ________________________________ Seal: Commission expires: __________ For official use only: Application received: ____________________________, 20_______ Registration: _______ Granted ________ Denied By: _____________________________________________________ Page 2 of 2 In-House Counsel Registration and/or Renewal Application Ch3Art12App1 Ammended 1/2012 Required pursuant to Neb. Ct. R. � 3-1202(A) Appendix 1 (Neb. Ct. R. � Chapter 3, Article 12) American LegalNet, Inc. www.FormsWorkFlow.com