APPLICATION FOR ADMISSION PRO HAC VICE FOR ARBITRATION PROCEEDINGS NOTE: This form cannot be submitted electronically because it requires an original signature and notarization. You may fill it out and print it for signature purposes or use it as a template and draft your own application (which must be identical to the one below). Name: Address: City, State, Zip: Telephone / Fax: E-mail (if any): State(s) to Which Admitted Bar/ ID Number Matter in which Applicant wishes to appear: Please include names of parties and short description of case including any identifying information such as the name of the arbitration, what type of case - e.g., NASD, court ordered, etc. Are you (the Applicant) currently suspended (either administratively or for disciplinary purposes) or disbarred from the practice of law in any state in any court (federal or state) or tribunal or agency? If yes, please explain: Have you (the Applicant) been disciplined by any state’s or court’s bar organization in the prior five (5) years? If yes, please explain: Are you (the Applicant) the subject of any pending disciplinary proceedings by any state’s or court’s bar organization? American LegalNet, Inc. www.FormsWorkflow.com Opposing Counsel information ( if known) : Name: Address: City, State, Zip: Telephone / Fax: E-mail (if known): Applicant’s Certification and Signature: Applicant certifies the following: • Applicant does not reside in Utah. • Applicant agrees to comply with the Utah Rules of Professional Conduct and consents to jurisdiction of the courts of Utah and the Utah State Bar. • All the information included in this application is accurate. • The information provided in this application is true and correct. Applicant must attach to this application an original Certificate of Good Standing from the licensing state which the applicant resides. Applicant’s Signature: ____________________________________________ STATE OF _______________ ) :ss COUNTY OF _____________ ) Signed and sworn to before me on _______________________ by ______________________________ Notary Public ___________________________________________________________ My appointment expires: __________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com