UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT ATTORNEY REGISTRATION TO BE COMPLETED ONLY IF YOU WERE PREVIOUSLY ADMITTED TO THE FOURTH CIRCUIT BAR NAME (present practicing name) Last _____________________________________________________________________________________ First ____________________________________ Middle _________________________________________ Generation (Jr.,Sr.,II,etc.) ___________ Title (if applicable) _______________________________________ Prefix (Mr.,Ms.,Professor,etc.) ________________________________________________________________ FIRM: ___________________________________________________________________________________ ADDRESS: _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ City ____________________________________________________________________________________ Zip Code ____________________________ Ext. __________ Fax (____)___________________________ State _________________________ Phone (____)___________________ E-mail____________________________________________________________________________________________ YEAR OF BIRTH: _______ APPROXIMATE DATE ADMITTED TO U.S. COURT OF APPEALS FOR THE FOURTH CIRCUIT __________________________________________________________________________________________ STATE OF RESIDENCE ____________________________________________________________________ IF ADMITTED UNDER A DIFFERENT NAME, PROVIDE NAME UNDER WHICH YOU WERE ADMITTED _______________________________________________________________________________ SCC 10/03/2011 American LegalNet, Inc. www.FormsWorkFlow.com