IN THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF VIRGINIA APPLICATION TO QUALIFY AS AN ATTORNEY OF THE UNITED STATES DISTRICT COURT FOR THE EASTERN DISTRICT OF VIRGINIA To: The Honorable Judges of the United States District Court for the Eastern District of Virginia PERSONAL STATEMENT FULL NAME (no initials, please) ____________________________________________________________________________ Virginia State Bar Identification Number ______________________________________________________________________ Firm Name ______________________________________________________________________________________________ Firm Phone # ________________________ Direct Dial # __________________________ FAX # ________________________ E-Mail Address __________________________________________________________________________________________ Office Mailing Address ____________________________________________________________________________________ Social Security Number ____________________________________ Date of Birth ____________________________________ I was born in (City, State, Country) ___________________________________________________________________________ My mother’ maiden name is (was) ___________________________________________________________________________ s I was naturalized at (Place) _____________________________________ on (Date) ____________________________________ I have been a practitioner since ______________________________________________________________________________ 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 qualified to practice in the Supreme Court of Virginia. I hereby certify that within ninety (90) days prior to the submission of this application I have read (a) The Federal Rules of Civil Procedure, (b) The Federal Rules of Criminal Procedure, (c) The Local Rules of this Court and (d) The Federal Rules of Evidence. _______________________________________ (Applicant’ Signature) s Subscribed and sworn to before me this ________ day of ____________________________, 20 ______. _______________________________________ (Notary Public) My commission expires ____________________ We, the undersigned, do certify that we are members of the bar of this Court, not related to the applicant; that we know the applicant personally, that the said applicant possesses all of the qualifications required for admission to the bar of this Court; that we have examined the applicant’ personal statement. We affirm that his/her personal and professional character and standing are good. s _______________________________________ _______________________________________ (Signature) (Signature) _______________________________________ _______________________________________ (Typed or Printed Name) (Typed or Printed Name) Are you interested in criminal appointments pursuant to the Criminal Justice Act? __________________ Do you request a Certificate of Good Standing so that you may apply for admission to the United States District Court for the Western District of Virginia? (additional $15.00 fee) Yes ________ No ________ American LegalNet, Inc. www.FormsWorkFlow.com OATH ON ADMISSION I do solemnly swear (or affirm) that I will demean myself as an attorney and counselor of this Court, uprightly and according to law; and that I will support the Constitution of the United States, so help me God. I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct. __________________________ __________________________ (Signature) (Date) Sworn and subscribed before me, __________________________ __________________________ (Deputy Clerk) (Date) Admitted on motion of ______________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com