UNITED STATES DISTRICT COURT FOR THE DISTRICT OF RHODE ISLAND Plaintiff(s) Case No.: v. Defendant(s) MOTION FOR ADMISSION PRO HAC VICE I, Court. I am moving for the admission of Attorney , am a member in good standing of the bar of this to appear pro hac vice in this case as counsel for _______________________________________________. I certify that I have reviewed the below information provided by the prospective admittee. I acknowledge and agree to observe the requirements of LR Gen 204 in its entirety and as it relates to the participation and responsibilities of local counsel. LOCAL COUNSEL: Name Signature Bar Number Date Firm/Agency Telephone Number Address Fax Number City, State, Zip Code E-mail Address TobecompletedbytheProspectiveAdmittee 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 (list courts below.) Admission Date State or Federal Court Admission Date State or Federal Court American LegalNet, Inc. www.FormsWorkFlow.com TobecompletedbytheProspectiveAdmittee If you answer yes to any of the below questions, you must provide a full explanation as an attachment. Have you ever been disciplined or sanctioned by any court or other body having disciplinary authority over attorneys? Are there any disciplinary proceedings pending against you at this time? Has your pro hac vice status ever been revoked by any court? Excluding traffic violations punishable by fine only, have you ever been convicted of, or entered a plea of no contest to, any crime? Are there any criminal charges pending against you at this time? CertificationandSignature YES NO YES YES NO NO YES YES NO NO For the purpose of this case, I have associated with local counsel identified in this motion, 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. I understand my obligation to notify this Court of any changed circumstances that affect my answers to the questions contained within this motion. 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. I hereby certify that the foregoing is true and correct. Respectfully submitted, PROSPECTIVE ADMITTEE: Name Signature Firm/Agency Telephone Number Address Fax Number City, State, Zip Code E-mail Address American LegalNet, Inc. www.FormsWorkFlow.com