UNITED STATES COURT OF APPEALS FOR THE ELEVENTH CIRCUIT Bar Membership Renewal Form Members of the bar of this Court are required to pay a renewal fee of $10 every five years [11th Cir. R. 46-2]. On or before the fifth anniversary of your admission (and each five years thereafter), please complete this form and submit it, along with any required attachments and the non-refundable $10 fee, via this Court's Electronic Case Files (ECF) system. 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. 2a. 2b. 3a. 3b. Within the last five years1, have you changed your name or been known by any names or surnames other than the one appearing on this renewal form? Within the last five years1, 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? Within the last five years1, 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? I certify that all information provided in this form, including attachments which are incorporated herein by reference, are true and correct to the best of my knowledge, information and belief. I further 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: Name (Type or Print): Last 4 digits of Social Security No.: E-Mail: Firm/Govt. Office: Street Address: City: 1 Phone: Fax: State: Zip: Within the last six years, if your bar membership in this court is currently in inactive status pursuant to 11th Cir. R. 46-2. Rev.: 12/16 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