(Effective 3/17/2008) UNITED STATES DISTRICT COURT FOR THE DISTRICT COURT OF RHODE ISLAND ______________________________ Plaintiff(s) v. Dkt. No._______________________ ______________________________ Defendant(s) APPLICATION FOR PRO HAC VICE ADMISSION (1) I am a member in good standing of the bar of every state and federal court to which I have been admitted, and my eligibility to practice before those courts has not been restricted in any way. (a) Please list all state courts: ____________________________________________________ __________________________________________________________________________ (b) Please list all federal courts: ___________________________________________________ __________________________________________________________________________ (2) Have you ever been disciplined or sanctioned by any court or other body having disciplinary authority over attorneys? Yes _____ No _____ (If Yes, please provide a full explanation.) (3) Are there any disciplinary proceedings pending against you at this time? Yes _____ No _____ (If Yes, please provide a full explanation.) (4) Has your pro hac vice status ever been revoked by any court? Yes _____ No _____ (If Yes, please provide a full explanation.) (5) Have you ever been convicted of a crime (other than minor traffic offenses)? Yes _____ No _____ (If Yes, please provide a full explanation.) (6) Are there any criminal charges pending against you at this time? Yes _____ No _____ (If Yes, please provide a full explanation.) (7) Have you appeared or applied for pro hac vice admission in this District during the past 12 months? Yes _____ No_____ (If Yes, please provide the date(s), case name(s) and name(s) of the judge(s) who presided). (8) I understand my obligation to notify this Court of any changed circumstances that affect my answers to the preceding questions. American LegalNet, Inc. www.FormsWorkFlow.com Pro Hac Vice Application Form (cont’d) (9) I have read, acknowledge, and agree to observe and be bound by the local rules and orders of this Court, including the Rules of Professional Conduct of the Rhode Island Supreme Court, as adopted by this Court as the standard of conduct for all attorneys appearing before it. (10) For the purpose of this case, I have associated with local counsel identified below, and have read acknowledge, and will observe the requirements of this Court respecting the participation of local counsel, as set out in LR Gen 204, recognizing that failure to do so may result in my being disqualified, either upon the Court’s motion or motion of other parties in the case. Name of Local Counsel: __________________________________________________________ I hereby certify that the foregoing is true and correct. _______________________________________ Signature of Pro Hac Vice Applicant ____________________________________________________________________________________ Print Name ____________________________________________________________________________________ Firm Name ____________________________________________________________________________________ Business Address ____________________________________________________________________________________ _________________________________________ Tel. # _______________________________________ Fax # *DO NOT FILE THIS FORM ELECTRONICALLY. File this completed form in a conventional manner along with the applicable fee. American LegalNet, Inc. www.FormsWorkFlow.com