Ct-01 United States District Court for the Western District of Tennessee Bar Admittee Change of Name/Address Form PLEASE TYPE OR PRINT LEGIBLY TO : Attorney Admissions Clerk, Clerk’s Office, Federal Building - Suite 242, 167 N. Main Street, Memphis, TN 38103 (901) 495-1200 FAX: (901) 495-1250 FROM : FORMER NAME, (if applicable): BAR # PLEASE CHECK AS APPLICABLE: CJA Panel Attorney Member Mediation Panel Member Pro Bono Plan Panel Member NEW Address: Firm Street/ PO box City, State, Zip Phone # Fax # Cell Phone # Email Address FORMER Address: Firm Street/ PO box City, State, Zip Phone # Fax # Cell Phone # Email Address Signature Date American LegalNet, Inc. www.FormsWorkflow.com