APPLICATION AND OATH FOR ADMISSION U. S. COURT OF APPEALS FOR THE FIFTH CIRCUIT, 600 S. Maestri Place, New Orleans, LA 70130 PERSONAL STATEMENT Name ____________________________________________________________________________________________________________________________________ (Last) (First) (Middle) Firm or Agency _____________________________________________________________________________________________________________________________ Street Address City & State Phone _______ E-Mail Address _______ Fax ________________ Date of Birth Zip Suite _______________________________________________ Social Security No. _________________________________ Cell Phone___________________________________ Sex: M F List State Bars to which admitted, and State Bar Numbers____________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________ Pursuant to FED. R. APP. P. 46(a), you must be a member in good standing of a federal or state court/bar. Please attach a certificate of good standing from a qualifying court identified below. (NOTE, a certificate of good standing is not required if you were initially admitted to a state bar or state supreme court within 30 days of this application or if you are an attorney working for the U.S. Government or U.S. Judiciary.) Court Date Admitted ________________________________ Please answer the following questions. Yes No 1. Have you ever been known by any name other than the one appearing on this application? If so, attach a list of all other names used. 2. Have you been disbarred, suspended from practice or received a reprimand pertaining to your conduct or fitness to practice law from any court, department, bureau or commission of any State or the United States? Are any such proceedings or allegations pending against you? If so, attach a detailed explanation containing dates and circumstances. 3. Are you presently under investigation, or have you been a party to criminal, or civil proceedings alleging fraud, misrepresentation or other dishonesty? If so, attach a detailed explanation. ADMISSION FEE: The $231 admission fee is to be paid via Pay.gov if filing this document electronically in CM/ECF. If this document is forwarded by mail, the fee is paid by check payable to "Clerk, United States Court." If claiming a fee exemption under 5th Cir. R. 46.1, mark as appropriate: Court Apptd. U.S. Counsel Newly Graduated Military Attorney 1 CASE NUMBER in Fifth Circuit (If Any), ______________________ 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 further swear (or affirm) all responses in my personal statement, including any attachments thereto, are true and correct to the best of my knowledge, information and belief. ______________________________________ Signature of Applicant Subscribed and sworn to before me a Notary Public in and for the parish/county of this day of 20 . , State of _____________________________ Signature of Notary As REQUIRED by Federal Rule of Appellate Procedure 46(a)(3), please have a current member of our bar complete the portion below: MOTION: I, (Please print or type) a member of the Bar of this Court, move the above attorney's admission. ___________________________ Signature 1 Please see attached note. DKT-5B American LegalNet, Inc. www.FormsWorkFlow.com __________________________________________________________________________________________________________________________ Note Regarding Newly Graduated Military Attorney Status: In August 2008, we amended 5th CIR. R. 46.1 to allow an admission fee waiver for newly graduated lawyers admitted to practice in Louisiana, Mississippi, and Texas; and on initial extended active duty orders for service in the Judge Advocate General's Corps of the armed forces. To claim an exemption please: 1) 2) 3) 4) Mark the Newly Graduated Military Attorney box; Provide a paper or electronic copy of your law school transcript, or other document from you school showing your graduation date; Provide a paper or electronic copy of your orders directing you to report for extended active duty with the Judge Advocate General's Corps; Provide documentation of bar admission. If you have questions call 504-310-7700. American LegalNet, Inc. www.FormsWorkFlow.com