UNITED STATES COURT OF APPEALS FOR THE ELEVENTH CIRCUIT Application for Admission to the Bar (Please Type or Print) Social Sec. No.: VERIFIED PERSONAL STATEMENT Name: Phone: (As you want it to appear on Certificate) Firm/Govt. Office: E-Mail: Street Address: Fax: City: State: Zip: Pursuant to Fed.R.App.P. 46(a), to qualify for admission you must be a member in good standing of the bar of the U.S. Supreme Court, another U.S. Court of Appeals, a U.S. District Court, or the highest court of any state. You must attach to this application (1) a certificate of good standing issued within the previous six months from one of the courts described above, and (2) a list of all state and federal bars of which you are a member, including state bar numbers, and your status with each bar (e.g., active, inactive, retired, etc.) . See 11th Cir. R. 46-7. (Answer each question. If any answer is yes, attach a statement giving details.) YES r r NO r r 1. 2a. r r r r 2b. 3a. r r 3b. Have you changed your name or been known by any names or surnames other than the one appearing on this application? Have you been disbarred or suspended from practice by any bar or before any court, department, bureau or commission of any State or the United States, or have you received a reprimand from any of them pertaining to your conduct or fitness to practice? Are any such proceedings or allegations presently pending against you? Have you been a party to criminal proceedings, or to civil proceedings in which allegations of fraud, misrepresentation or other dishonesty were made against you? Are you presently under investigation for any matter specified in question 3a? OATH (OR AFFIRM ATION) I, do solemnly swear (or affirm) that I will conduct myself as an attorney and counselor of this court, uprightly and according to law; and that I will support the Constitution of the United States. I do further swear (or affirm) that all responses in the foregoing personal statement, including attachments which are incorporated herein by reference, are true and correct to the best of my knowledge, information and belief. I certify that, except as otherwise noted, I am an active member in good standing of each state bar or the bar of the highest court of each state (including the District of Columbia) listed on the attached sheet, and that my license to practice law in the named state is not currently lapsed for any reason, including but not limited to retirement, placement in inactive status, failure to pay bar membership fees or failure to complete continuing education requirements. I understand that I am required to notify the clerk of this court within 14 days of any changes in the status of my state bar memberships. See 11th Cir. R. 46-7. Signature of Applicant Subscribed and sworn (or affirmed) to before me a Notary Public in and for the County of , State of , this day of . My commission expires: Signature and Seal of Notary OPTIONAL MOTION (a certificate of good standing issued within the previous six months from your qualifying court is still required): (Please Type or Print) I, , a member of the bar of the Eleventh Circuit Court of Appeals, hereby move the admission of the applicant to the bar of this court. I am satisfied that the applicant possesses the necessary qualifications and is of good moral and professional character. Social Security Number of Movant Signature of Movant NOTE: Make check payable to “Clerk, U.S. Court of Appeals, Eleventh Circuit,” and attach to your application. The completed application, a certificate of good standing issued within the previous six months from your qualifying court, a list of all state and federal bars of which you are a member (including state bar numbers and your status with each bar), and $170 admission fee should be forwarded to: Attorney Admissions Clerk, U.S. Court of Appeals, Eleventh Circuit, 56 Forsyth Street, N.W., Atlanta, GA 30303. 10/09 American LegalNet, Inc. www.FormsWorkFlow.com LIST OF BAR MEMBERSHIPS You must attach a list of all bars of which you are a member, including state bars and state and federal courts to which you are admitted to practice. The list must also include bar numbers (if any), the date of admission, and your status with each bar or court (e.g., active, inactive, retired, etc.). See 11th Cir. R. 46-7. You may use this page to fulfill this requirement. Name of State or Federal Bar or Court Bar Number (if any) Date Admitted Status with Bar or Court (active, inactive, retired, etc.) 2 American LegalNet, Inc. www.FormsWorkFlow.com