Regulatory Service Department Coversheet for APR 8(b) E xception for Particular Action or Proceeding (Pro Hac Vice) Note: Only one applicant and case per coversheet. Please print or type. Your cancelled check serves as your receipt. This form must be filed together with a copy of the motion and payment of the $479 nonrefundable fee to: Washington State Bar Association 1325 4th Ave. Ste 600 Seattle, WA 98101-2539 1. Applicant Seeking Admission: Full Name: Employer Name: Business Address: Business Phone: Email: Licensed in State: Bar Number: I qualify for the indigent military ICWA exception as provided for in APR 8(b). 2. Associated Washington Lawyer: Full Name: Employer Name: Business Address: Business Phone: Email: Licensed in State: Bar Number: 3. Case for Which Admission Is Sought: Case No. Court Name of Case 4. Application Fee Paid By: For Credit Card Payment: Note: Our service provider will charge you a separate, non-refundable transaction fee of 2.5% on all bank card transactions. There is no transaction fee if you mail in a check. MC/Visa/Amex No: Exp.: (Circle One) Billing Address (if different from above): Street or PO Box City State Zip Code Name on Card: Signature: (Please Print) For office use only Pro Hac Vice Fees 42290 ADMISS Date A mount $ Check No. App. No. American LegalNet, Inc. www.FormsWorkFlow.com