APPLICATION FOR ADMISSION TO THE BAR FOR THE WESTERN DISTRICT OF TENNESSEE LOCAL RULE 83.4 Attorneys - Admission This form must be returned to the Clerk's Office for processing, along with a $176.00 payment at the time of admission. PLEASE COMPLETE THE FOLLOWING: 1. Are you licensed to practice law? _____No _____Yes ______________________________ List State(s) 2. Date of admission: ________________________________ 3. Are you a member in good standing of the Bar of the Supreme Court in the State above? _____Yes _____No 4. State Bar Number: ___________________________________________________ 5. Applicant's Name: _________________________________________________________ (Please print your name as it should appear on the certificate .) Applicant's Signature: ___________________________________________________ Home Address: __________________________________________________________ ___________________________________________________________ Office Address: ___________________________________________________________ ___________________________________________________________ Firm Name: ___________________________________________________________ Phone: ___________________________________________________ Fax No.: ___________________________________________________ Email Address: ____________________________________________________________ --------------------------------------------------------------------------------------------------United States District Court for the Western District of Tennessee ORDER ADMITTING ATTORNEY On motion of ______________________________________, Esq., a member in good standing of the Bar of this Court, the above referenced attorney is hereby admitted to practice in the United States District Court as an Attorney, Counselor, Solicitor, Proctor, and Advocate, and is hereby duly sworn by the Clerk of this Court. This _______ day of _______________, 20____. ___________________________________________________ UNITED STATES (DISTRICT)(MAGISTRATE) JUDGE Revised 07/2012 American LegalNet, Inc. www.FormsWorkFlow.com