BTXN 104a (rev. 09/12) UNITED STATES BANKRUPTCY COURT NORTHERN DISTRICT OF TEXAS In Re: � � � � � � Case No.: Debtor(s) APPLICATION FOR ADMISSION PRO HAC VICE 1. Name: ________________________________________________________________ Last First MI 2. 3. Firm Name: ____________________________________________________________ Address: ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ 4. Phone: ____________________________ FAX: _____________________________ Email: ______________________________________ 5. 6. 7. Name used to sign all pleadings: ___________________________________________ Retained by: ___________________________________________________________ Admitted on __________________________ and presently a member in good standing of the bar of the highest court of the state of __________________________________ and issued the bar license number of __________________________ . 8. Admitted to practice before the following courts: Court: ____________________________________ ____________________________________ ____________________________________ Admission Date: _________________________ _________________________ _________________________ Continued. American LegalNet, Inc. www.FormsWorkFlow.com 9. Are you presently a member in good standing of the bars of the courts listed above? Yes No If "No," please list all courts which you are no longer admitted to practice: 10. Have you ever been subject to a grievance proceeding or involuntary removal proceeding while a member of the bar of any state or federal court? Yes No If "Yes," please provide details: 11. Other than minor traffic offenses, have you ever been charged, arrested, or convicted of a criminal offense or offenses? Yes No If "Yes," please provide details: 12. Please list all cases in the United States Bankruptcy Court, Northern District of Texas in which you have filed for pro hac vice in the past three years: Date of Application __________________ __________________ __________________ Case No. and Style _______________________________________________ _______________________________________________ _______________________________________________ 13. 14. Local counsel of record: ___________________________________________________ Local counsel' address: ___________________________________________________ s _______________________________________________________________________ Continued. American LegalNet, Inc. www.FormsWorkFlow.com I respectfully request to be admitted to practice in the United States Bankruptcy Court for the Northern District of Texas for this cause only. I certify that I have read Dondi Properties Corp. V Commerce Savs. & Loan Ass'n, 121 F.D.R. 284 (N.D. Tex. 1988) (en banc), and the local civil and bankruptcy rules of this court and will comply with the standards of practice adopted in Dondi and with the local civil and bankruptcy rules. I am an ECF filer. I also certify that I have served a true and correct copy of this document upon each attorney of record and filed the application via ECF with the payment of $25.00 I am not an ECF filer. I also certify that I have served a true and correct copy of this document upon each attorney of record and the original upon the US Bankruptcy Court accompanied with the $25.00 filing fee on ________________. _______________________________ Printed Name of Applicant ____________________ Date _______________________________ Signature of Applicant American LegalNet, Inc. www.FormsWorkFlow.com