002002 002002 UNITED STATES DISTRICT COURT DISTRICT OF OREGON Plaintiff(s), Case No.: APPLICATION FOR SPECIAL ADMISSION PRO HAC VICE v. Defendant(s). Application for Pro Hac Vice Admission and CM/ECF Registration Attorney requests special admission pro hac vice to the Bar of the United States District Court for the District of Oregon in the above-captioned case for the purposes of representing the following party(s): In support of this application, I certify that: 1) I am an active member in good standing with the State Bar; and 2) that I have read and am familiar with the Federal Rules of Evidence, the Federal Rules of Civil and Criminal Procedure, the Local Rules of this Court, and this Court's Statement of Professionalism. I understand that my admission to the Bar of the United States District Court for the District of Oregon is solely for the purpose of litigating in the above matter and will be terminated upon the conclusion of the matter. (1) PERSONAL DATA: U.S. District Court Oregon Application for Special Admission Pro Hac Vice [Rev. 03/2018] Page 1 of 5 Name: (Last Name) (First Name) (MI) (Suffix) Agency/firm affiliation: Mailing address: American LegalNet, Inc. www.FormsWorkFlow.com 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003003003003003003 002002002002002002002 002 002 002 002 002 003 003 City: State: Zip: Phone number: Fax number: Business e-mail address: (2)003 003 003 003 003 003 003 EDUCATION: (a) 003 003 003 003 003 003 003 Undergraduate School: City: State: Year Graduated: Degree(s): (b)003 Graduate School:City: State: Year Graduated: Degree(s): (c)003 Law School: City: State: Year Graduated: Degree(s):(3)003 BAR ADMISSION INFORMATION: (a)003 State bar admission(s), date(s) of admission, and bar number(s): (b)003 Other federal court admission(s) and date(s) of admission: (4)003 CERTIFICATION OF DISCIPLINARY ACTIONS: 003 003 003 003 003 003 003 I am not now, nor have I ever been subject to any disciplinary action by any state or federal bar association. 003 I am now or have been subject to disciplinary action by a state or federal bar 002association. (See attached letter of explanation.)002 U.S. District Court Oregon003 Application for Special Admission Pro Hac Vice [Rev. 03/2018]003 Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com (5) CERTIFICATION OF PROFESSIONAL LIABILITY INSURANCE: I have professional liability insurance, or financial responsibility equivalent to liability insurance, that meets the insurance requirements of the Oregon State Bar for attorneys practicing in this District, and that will apply and remain in force for the duration of the case, including any appeal proceedings. (6) CM/ECF REGISTRATION: I acknowledge that I will become a registered user of the Court's case management and electronic case filing system (CM/ECF) upon approval of this application, and I consent to electronic service pursuant to Fed. R. Civ. P. 5(b)(2)(E) and the Local Rules of the District of Oregon. Certification of Attorney Seeking Pro Hac Vice Admission: I have read and understand the requirements of LR 83-3, and I certify that the above information is true and correct. DATED: . (Signature) U.S. District Court Oregon Application for Special Admission Pro Hac Vice [Rev. 03/2018] Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 003 REQUIREMENT TO ASSOCIATE WITH LOCAL COUNSEL: LR 83-3(a)(1) requires applicants for pro hac vice admission to associate with local counsel, unless requesting a waiver of the requirement under LR 45-1. To request a waiver of the requirement to associate with local counsel under LR 45-1, check the following box: 003 I seek admission for the limited purpose of filing a motion related to a subpoena that this Court did not issue. Pursuant to LR 45-1(b), I request a waiver of the LR 83-3(a)(1) requirement to associate with local counsel and therefore do not include a certification from local counsel with this application. To associate with local counsel, complete the following section and obtain the signature of local counsel. Name: (Last Name) OSB number : Agency/firm affiliation: Mailing address: City: Phone number: (First Name) (MI) Date admitted: State: Zip: Fax number: (Suffix) Business e-mail address: CERTIFICATION OF ASSOCIATE LOCAL COUNSEL: I certify that I am a member in good standing of the bar of this Court, that I have read and understand the requirements of LR 83-3, and that I will serve as designated local counsel in case number . DATED: . (Signature of Local Counsel) U.S. District Court Oregon003 Application for Special Admission Pro Hac Vice [Rev. 03/2018]003 Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 002 002 002 002 002 002 002 002 002 002 002 002 002 002 002 002 002 002 COURT ACTION002 Application for pro hac vice admission by in case number is hereby: Approved subject to payment of fees.002 Denied.002 DATED: . United States District Judge U.S. District Court Oregon Application for Special Admission Pro Hac Vice [Rev. 03/2018] Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com