UNITED STATES BANKRUPTCY COURT EASTERN DISTRICT OF VIRGINIA APPLICATION TO QUALIFY AS AN ATTORNEY FOR THE UNITED STATES BANKRUPTCY COURT FOR THE EASTERN DISTRICT OF VIRGINIA PERSONAL STATEMENT Full name: _____________________________________________________________________________ Residence address: ______________________________________________________________________ Firm: _________________________________________________________________________________ Office address: _________________________________________________________________________ Office telephone no: ____________________________ Social Security No: _______________________ Place of birth: _______________________________________ Date of birth: _______________________ Legal education (including degrees): ________________________________________________________ _________________________________________________________ State Bar No: _________________ Dates and places of practice: ______________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ I was qualified to practice in the Supreme Court of Virginia on ___________________________________. I will keep the Court informed of any changes in the above personal information. I have not been reprimanded in any court nor has there been any action in any court pertaining to my conduct or fitness as a member of the bar. I am a member in good standing of the VirgiState Bar ania nd have paid all necessary license fees. I have read the Federal Rules of Civil Proceduree Fed, th eral Rules of Evidence, the Rules of Bankruptcy Procedure and the Local Rules of theUnited States Bankruptcy Court for the Eastern District of Virginia within the past ninety days. I hereby swear (or affirm) under the penalty of perjury that the foregoing is true and correct. __________________________________________________ e as it will appear on futu [Sign name as it will appear on futu ENDORSEMENT We, the undersigned, do certify that we are membof the bers ar of this Court; are resident practitioners within the Commonwealth of Virginia; we know the applicant personally; the said applicant possesses all of the qualifications for the practice of bankruptcy alaw;nd that we have examined the applicants personal statement. We affirm that his (her) personal and professional character is oodg. [Local Rule 2090-1(C)] Date: ______________________ Print Name: _______________________________________ Signature: _______________________________________ Date: ______________________ Print Name: _______________________________________ Signature: _______________________________________ [ver. 4/2005] American LegalNet, Inc. www.USCourtForms.com