IN THE CHANCERY COURT FOR DAVIDSON COUNTY, TENNESSEE TWENTIETH JUDICIAL DISTRICT AFFIDAVIT OF ____________________________________ (Pro Hac Vice Applicant) Before me, the undersigned, personally appeared _______________________________. (Pro Hac Vice Applicant) (1) My full name is: _________________________________________________________ My residence address is: __________________________________________________ My firm name is: ________________________________________________________ My office address is: _____________________________________________________ Other jurisdictions licensed & registration/identifying numbers are: _______________________________________________________________________ _______________________________________________________________________ Full name or style of case in which I seek to appear: _______________________________________________________________________ _______________________________________________________________________ Name of the client or clients I seek to represent: _______________________________________________________________________ (2) The jurisdiction(s) in which licensed to practice law, with date(s) of admission: _______________________________________________________________________ Any other courts in which admitted to practice, with date(s) of admission: _______________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Statement of good standing in all other jurisdictions in which applicant is licensed to practice law: ________________________________________________________________________ ________________________________________________________________________ (3) Full name or style of each case in which applicant was previously admitted or sought to be admitted pro hac vice in any trial or appellate court of Tennessee within the preceding three years, date of any such admission or the date of any such motion that was filed but not granted, and the status of any such case in which not admitted: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ (4) Statement concerning whether the applicant lawyer has previously been denied admission pro hac vice or has had an admission pro hac vice revoked by any court in any jurisdiction and, if so, a full description of the circumstances, including the full name or style of the case: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ (5) Statement concerning whether the applicant lawyer has ever been disciplined or sanctioned by the Board of Professional Responsibility of the Supreme Court of Tennessee, by any similar lawyer disciplinary agency in any jurisdiction, or by any similar lawyer disciplinary authority and, if so, a full description of the circumstances, including the full name or style of the matter: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ (6) Statement concerning whether any disciplinary or investigation concerning the applicant lawyer’s conduct is pending before the Board of Professional Responsibility of the Supreme Court of Tennessee, before any similar lawyer disciplinary agency in any American LegalNet, Inc. www.FormsWorkFlow.com jurisdiction, or before any similar lawyer disciplinary authority and, if so, a full description of the circumstances, including the full name or style of the matter: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ (7) Statement that the applicant lawyer is familiar with the Tennessee Rules of Professional Conduct and the rules governing the proceedings of the court before which the lawyer seeks to practice: _______________________________________________________________________ _______________________________________________________________________ (8) Statement that the applicant lawyer consents to the disciplinary jurisdiction of the Board of Professional Responsibility of the Supreme Court of Tennessee and the courts of Tennessee in any matter arising out of the lawyer’s conduct in the proceeding and that the lawyer agrees to be bound by the Tennessee Rules of Professional Conduct and any other rules of conduct applicable to lawyers generally admitted in Tennessee: _______________________________________________________________________ _______________________________________________________________________ (9) Tennessee lawyer with whom the applicant lawyer is associated: Name: __________________________________________ Address: _______________________________________________________________ Telephone No.: _________________________ TN Bar No.: ____________________ (10) Statement that the applicant lawyer has paid all fees required by this Rule in connection with the motion for admission: _______________________________________________________________________ (11) At the option of the applicant lawyer, any other information supporting the lawyer’s admission: _______________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com (12) Statement indicating service of the pro hac vice motion and all associated papers upon all counsel of record in the proceeding and upon the Board of Professional Responsibility of the Supreme Court of Tennessee: ________________________________________________________________________ ________________________________________________________________________ (13) A certificate of good standing from the court of last resort of the licensing jurisdiction in which the applicant principally practices, or resides, is attached as an Exhibit to this affidavit and incorporated herein. I declare under penalty of perjury that the foregoing is true and correct. ____________________________________ Pro Hac Vice Applicant Sworn to and subscribed before me this _____ day of __________________, 20 ___. ______________________________________ Notary Public My commission expires: _________________ American LegalNet, Inc. www.FormsWorkFlow.com