UNITED STATES COURT OF APPEALS FOR THE ELEVENTH CIRCUIT Application to Appear Pro Hac Vice Court of Appeals Docket No. Name: Phone: Firm/Office: Fax: Street Address: E-mail: City: State: Zip: Name of party/parties to be represented: Pursuant to 11th Cir. R. 46-4, this application must be accompanied by (1) a certificate of good standing issued within the previous six months establishing that you are admitted to practice before a court described in FRAP 46(a)(1), (2) proof of service on the other parties in compliance with FRAP 25(d), and (3) a check in the amount of $50 made payable to 223U.S. Court of Appeals Non-Appropriated Fund, 11th Circuit.224 You must attach 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 and relevant documentation. YES NO 1. Have you changed your name or been known by any names or surnames other than the one appearing on this application? 2a. Have you been disbarred or suspended from practice before any court, department, bureau or commission of any State or the United States, or have you been admonished, sanctioned, or reprimanded by any of them pertaining to your conduct or fitness to practice? 2b. Are any such proceedings or allegations presently pending against you? 3a. Have you been a party to criminal proceedings? 3b. Have you been a party to civil proceedings in which allegations of fraud, misrepresentation, or other dishonesty were made against you? 3c. Are any proceedings or allegations presently pending against you for any matter specified in question 3a or 3b? 4. Have you previously applied to this court for pro hac vice admission in any proceeding? If so, when? OATH (OR AFFIRMATION) 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 statements and responses in my application to appear pro hac vice, 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, while this matter remains pending. See 11th Cir. R. 46-7. Date: Signature: Last 4 digits of attorney222s Social Security No. (for positive identification purposes): Rev.: 8/18 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.) NOTE: This application accompanied by all required items noted above should be forwarded to: Clerk, U.S. Court of Appeals, Eleventh Circuit, 56 Forsyth Street, N.W., Atlanta, GA 30303. American LegalNet, Inc. www.FormsWorkFlow.com NOTICE We invite your particular attention to the following items: You must serve a copy of the application, with attachments, on the other parties to the appeal or review, and provide us with a 223proof of service224 (sometimes known as a certificate of service). See FRAP 25(b), (d). The Certificate of Good Standing that you submit must be an original (not a copy) and must establish that you are admitted to practice before a court described in FRAP 46(a)(1). If you have a question about a particular Certificate of Good Standing, you are welcome to call the Clerk222s Office for guidance, at 404-335-6100. If you answered any question 223yes,224 you must provide a statement giving details and relevant documentation, such as a copy of a complaint filed against you or an order imposing discipline. Your signature must be a 223wet224 signature; an electronic signature will not suffice. You must mail your paper application with attachments to this Court; we do not accept e-filed applications. Notice to Customers Presenting Checks When you provide a check as payment, you authorize us either to use information from your check to make a one-time electronic fund transfer from your account or to process the payment as a check transaction. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day you make your payment. American LegalNet, Inc. www.FormsWorkFlow.com