UNITED STATES DISTRICT COURT FOR THE DISTRICT OF RHODE ISLAND APPLICATION FOR REINSTATEMENT I, ________________________________________ hereby apply for reinstatement to the bar of the United States District Court for the District of Rhode Island pursuant to LR Gen 215(a)(1). 1. Full name: ______________________________________________________________ Business Address: ________________________________________________________ Firm name ________________________________________________________ Street Address and Suite ________________________________________________________ City, State and Zip Code Telephone Number: _______________________ Fax Number: ___________________ Email Address: __________________________________________________________ 2. Provide a detailed explanation of the circumstances (e.g. Disbarment, suspension, failure to register pursuant to LR Gen 203(d)) which caused you to lose membership to the bar of this Court. (Attach a separate statement if necessary.) 3. Explain your reasons for seeking reinstatement. American LegalNet, Inc. www.FormsWorkFlow.com 4. Have you ever been disbarred, suspended or been subjected to any other disciplinary action by any court or body having disciplinary authority over attorneys? Q Yes Q No If yes, state the dates, the facts, the disposition of each matter, and the name and address of the authority in possession of the record thereof. (Attach a separate statement.) 5. Is there any other incident in your career having a bearing upon your character or fitness for reinstatement to this bar? Q Yes Q No If yes, give full details on a separate statement. 6. Have you ever been convicted of a serious crime as defined in LR Gen 213(a)(3)? Q Yes Q No If yes, give full details on a separate statement. 7. Are you in good standing as an attorney admitted to practice before the Bar of the Supreme Court of the State of Rhode Island and any other court whose certificate you submitted upon your request for admission to this bar? Q Yes Q No If no, give full details on a separate statement. I have read the foregoing application for reinstatement to the bar of the U.S. District Court for the District of Rhode Island and have answered all questions fully and frankly. The answers are complete and are true of my own knowledge. ____________________________________ Signature of Applicant ____________________________________ Bar Number ____________________________________ Date (Rev. 5/28/2013) American LegalNet, Inc. www.FormsWorkFlow.com