APPLICATION TO APPEAR PRO HAC VICE BEFORE A VIRGINIA TRIBUNAL I, , the APPLICANT FIRST NAME MIDDLE NAME LAST NAME SUFFIX undersigned attorney, hereby apply to this tribunal of the Commonwealth of Virginia, , to appear as counsel pro hac vice pursuant to Rule 1A:4 of the Rules of the Supreme Court of Virginia. I further state the following: 1. The case in which I seek to appear pro hac vice is styled , has and is pending in docket number . This case is is not a related or consolidated matter for which I have previously applied to appear pro hac vice. I have previously applied to appear pro hac vice in the following related or consolidated matters: a. DOCKET NUMBER COURT NAME DATE OF PRO HAC VICE APPLICATION STYLE OF RELATED OR CONSOLIDATED MATTER DOCKET NUMBER COURT NAME DATE OF PRO HAC VICE APPLICATION STYLE OF RELATED OR CONSOLIDATED MATTER b. Additional Sheet attached. 2. APPLICANT’S RESIDENCE APPLICANT’S OFFICE ADDRESS 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com 3. NAME OF LOCAL COUNSEL VSB NUMBER STREET ADDRESS FAX NUMBER 4. EMAIL ADDRESS TELEPHONE NUMBER NAME OF PARTY TO CASE NAME AND ADDRESS OF COUNSEL FOR PARTY NAME OF PARTY TO CASE NAME AND ADDRESS OF COUNSEL FOR PARTY NAME OF PARTY TO CASE NAME AND ADDRESS OF COUNSEL FOR PARTY Additional sheet attached. 5. COURT TO WHICH APPLICANT IS ADMITTED DATE OF ADMISSION BAR # COURT TO WHICH APPLICANT IS ADMITTED DATE OF ADMISSION BAR # Additional sheet attached. 6. I am a member in good standing and authorized to appear in the courts identified in paragraph 5. 7. I am not currently disbarred or suspended in any state, territory, United States possession or tribunal. 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com 8. I am not subject to a pending disciplinary investigation or proceeding by am subject to a pending disciplinary investigation or proceeding by any court, agency or organization authorized to discipline me as a lawyer. (If such an investigation or proceeding is pending, attach to this application and incorporate by reference a statement specifying the jurisdiction, the nature of the matter under investigation or being prosecuted, and the name and address of the disciplinary authority investigating or prosecuting the matter.) 9. Within the past three (3) years, I have not been disciplined have been disciplined by any court, agency or organization authorized to discipline me as a lawyer. (If so, attach to this application and incorporate by reference a statement specifying the name of the court, agency or organization imposing discipline, the date(s) of such discipline, the nature of the complaint or charge on which discipline was imposed, and the sanction.) 10. Within the last twelve (12) months preceding this application, I have not sought admission pro hac vice under this rule. have sought admission pro hac vice under this rule. (If so, attach to this application and incorporate by reference a copy of the order of the tribunal granting or denying your previous application. Such order(s) must include the name of the tribunal, the style of case and the docket number for the case(s) in which you filed an application and whether the application was granted or denied.) Order(s) attached and incorporated by reference. 11. I hereby consent to the jurisdiction of the courts and agencies of the Commonwealth of Virginia and of the Virginia State Bar and I further consent to service of process at any address(es) required by this Rule. 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com 12. I agree to review and comply with appropriate rules of procedure as required in the case for which I am applying to appear pro hac vice. 13. I understand and I agree to comply with the rules and standards of professional conduct required of members of the Virginia State Bar. ............................................. DATE ................................................................................ SIGNATURE OF APPLICANT Commonwealth/State of ....................................................................... [ ] City [ ] County of .......................................................................... Subscribed and sworn to/affirmed before me on this date by the above-named person. ............................................. DATE ................................................................................ NOTARY PUBLIC My commission expires: .................................. 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com