Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Pro Bono Program (06/2018) Page 1 of 4 Instructions: Applicants who successfully completed the Pro Bono Scholars Program must submit this form with their application for admission. The applicant must provide the information requested on page one of the academic component must complete the Faculty Supervisor Certification. The completed original form must then TO BE CERTIFIED UNDER OATH BY APPLICANT: Name of Applicant � BOLE ID # (NYS Board of Law Examiners Identification Number) � Address of Applicant � City/Town/Village � State � ZIP � Name of Law School From Which You Graduated � Name of Law School, Law Firm, Corporation or Entity Where Pro Bono Placement Was Completed � Address of School, Firm, Corporation or Entity Where Pro Bono Placement Was Completed � City/Town/Village � State � ZIP � Dates of Service: From (mm/dd/yyyy): / / To (mm/dd/yyyy): / / Total Hours of Pro Bono Service Completed: Total Academic Component Hours Completed: Total Credits Earned In Pro Bono Scholars Program: Description of the Nature of the Pro Bono Service Completed (Include details regarding work performed, such as the type of client matters you handled, the substantive law involved, and the law-related activities in which you engaged.) B American LegalNet, Inc. www.FormsWorkFlow.com Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Pro Bono Program (06/2018) Page 2 of 4 STATE (COUNTRY) OF � � COUNTY OF � � CITY OF � I (name of applicant), , SWEAR (OR AFFIRM) that the Signature of Applicant Dated (mm/dd/yyyy) Subscribed and sworn to or affirmed before me this day of in the year 20 . Notary Public*(Sign & Affix seal or stamp) * � If this affidavit is sworn to outside the United States, its commonwealths, territories or possessions, and the attesting officer is not a notary public, attach American LegalNet, Inc. www.FormsWorkFlow.com Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Pro Bono Program (06/2018) Page 3 of 4 TO BE COMPLETED BY PLACEMENT SUPERVISOR:I HEREBY CERTIFY (a) that I have read the foregoing affidavit of compliance and (b) that the applicant has Yes No I HEREBY PROVIDE ANY OTHER FACTSSignature of Attorney Dated (mm/dd/yyyy) � � Jurisdiction Where Admitted to Practice Law � Telephone � Email � SUPERVISOR CERTIFICATION American LegalNet, Inc. www.FormsWorkFlow.com Application for Admission to Practice as an Attorney and Counselor-at-Law in the State of New York: Pro Bono Program (06/2018) Page 4 of 4 TO BE COMPLETED BY FACULTY SUPERVISOR:I HEREBY CERTIFY (a) that I have read the foregoing Affidavit of Compliance and (b) that the applicant has successfully completed the academic component of the Pro Bono Scholars Program, and (c) that the applicant has been awarded at least 12 credits for participation in the program.Signature of Faculty Member Dated (mm/dd/yyyy) � City/Town/Village � State � ZIP � Telephone � Email � Comments (if further explanation is necessary: SUPERVISOR CERTIFICATION American LegalNet, Inc. www.FormsWorkFlow.com