IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF TEXAS APPLICATION FOR ADMISSION Instructions: Type or print your answers. Answer all questions fully. If the question does not apply to you, answer "NA". An incomplete response will delay processing of your application. Where the space provided is insufficient, answer on additional sheets, with reference to the question. Applicant Information 1. (a) Full Name (Last) (First) (Middle) (b) If you have ever been known by any other name, state the name and the reason for using it: Your name as you wish it to appear on the register: Date of Birth: Place of Birth: If not native born, give date and place of naturalization: (c) 2. (a) (b) (c) 3. 4. Business Name: Business Address: City, State, Zip: County: ( ) ) 5. (a) (b) (b) Business Telephone: Business Fax: ( Business e-mail: 6. 7. State Bar I.D. Number: Residence Address: City, State, Zip: County: ( ) 8. 9. Residence Telephone: Social Security Number1: 1 ______________________ Attorneys are requested to provide their Social Security Number in order to assist the court in maintaining the integrity of its records. Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Rev: April 29, 2014 Bar Affiliation 10. State List states, federal possessions and territories in which you have been admitted to practice law by the highest court. Indicate the year admitted, status, and areas of certified specialization. Year Admitted Current Standing Specialization 11. Court List federal courts to which you have been admitted. Indicate the year admitted and current status. Year Admitted Current Standing Education 12. List your law school, the date of graduation, and the degree received. If you did not graduate from a law school, please describe your law study in detail. Good Standing 13. Indicate any grievances or involuntary removals filed against you as a lawyer. Describe the circumstances in detail. 14. Describe in detail charges, arrests, or convictions for criminal offense(s). Omit minor traffic offenses. Rev: April 29, 2014 Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com ANSWER THE FOLLOWING QUESTIONS "YES" OR "NO" IN THE BLANK PROVIDED; IF "YES", EXPLAIN FULLY ON A SEPARATE SHEET. 15. (a) Have you ever been denied admission to the bar of any State (including the District of Columbia) or any federal court? ________ (b) Have you ever been disbarred, suspended from practice, reprimanded, censured or otherwise disciplined or disqualified as an attorney? ________ (c) Has any adverse action, formal or informal, been taken against you or your license to practice law by any grievance committee, court, or other disciplinary body or committee? ________ 16. 17. (a) Have you ever held a bonded position in connection with which anyone has sought to recover on your bond, or made a claim for any alleged default? ________ In connection with questions 17(a) through (c), the detailed explanation of any affirmative answers shall include dates, exact name and address of the court, if any, the case number, and disposition. (a) Have you ever been charged with any violation of any law, other than minor traffic violations? ________ (b) Have you ever been charged with fraud, formally or otherwise, in any civil, criminal, bankruptcy, or administrative case or proceeding? ________ (c) Have you ever been denied a discharge in bankruptcy, or had your discharge in bankruptcy revoked? ________ 18. Are there any unsatisfied judgments against you, whether barred by limitation or not? ________ (If so, give names and addresses of creditors, amounts, dates and nature of judgments, courts, and reasons for non-payment.) Electronic Case Filing Registration By submitting this form, I agree to abide by all Court rules, orders, policies and procedures governing the use of the electronic filing system. I also consent to service by electronic means in the circumstances permitted under those rules, orders, policies, and procedures. I further consent to allow the court to provide e-mail notifications on my behalf to all parties registered with the ECF System in lieu of providing certificate of service per Local Court Rule CV-5 and CR-49. I understand that the combination of user id and password will serve as the signature of the filing user filing the documents pursuant to Rule 11 of the Federal Rules of Civil Procedure, the Federal Rules of Criminal Procedure and the Local Rules of this court. Therefore as a filing user, I agree to protect the security of my password and immediately notify the Court if I suspect my password has been compromised. I already have an ECF login that I use at another Court, which is ____________________. Please assign the same login, if possible. (Important Note: This login cannot be your current PACER login.) Signature of Registrant Date Signed Primary E-mail Address Courtesy E-Mail Address Courtesy E-Mail #2 Address Rev: April 29, 2014 Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Certification and Signature I swear that the information provided in the foregoing application including attachments, if any, is true and correct. I acknowledge that by accepting admission to this Court I am subjecting myself to the discipline of this Court. I further certify that I have read and am familiar with the Federal Rules of Civil Procedure and Local Rules of this court and alternative dispute resolution procedures of the Western District of Texas and will advise clients in any actions pending in this court regarding alternative dispute resolution procedures. I further certify, if requested, I am willing to appear before this court or any Committee appointed to test the qualifications of applicants for admission to practice before this Court. I declare under penalty of perjury that the foregoing is true. Date Signature SUBSCRIBED AND SWORN TO BEFORE ME THIS ______ DAY OF ___________________________ 20___, at ________________________________________________. (SEAL) Notary Public or Deputy Clerk of this Court Rev: April 29, 2014 Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com