CA-190, 02/19 Application for Pro Hac Vice This form meets the requirements of Appendix A-2 to SCR 10.03 SCR 10.03(4) STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Case Caption: Application for Pro Hac Vice Admission Under SCR 10.03(4)(c) or (cm) Case No. I DECLARE UNDER PENALTY OF PERJURY: 1. That I seek to appear pro hac vice in order to represent in the above-captioned matter; 2. That I am nonresident military counsel seeking admission under SCR 10.03(4)(c) or nonresident counsel seeking to appear for the limited purpose of participating in a child custody proceeding pursuant to the Indian Child Welfare Act of 1978, 25 U.S.C. s. 1901, et seq., under SCR 10.03(4)(cm). 3. That I am admitted to practice law in the highest court(s) of the state(s) or country(ies) of ; 4. That I am admitted to practice law before the court(s) of the following federally recognized Indian tribes: ; 5. That there are no disciplinary complaints filed against me for violation of the rules of those courts (if so, please explain): ; 6. That I am not suspended or disbarred from practice for disciplinary reasons or reason of medical incapacity in any jurisdiction (if yes, please explain): ; 7. That I do not practice or hold out to practice law in the State of Wisconsin; 8. That I acknowledge the jurisdiction of the courts of the State of Wisconsin over my professional conduct, and I agree to abide by the rules of the relevant division of the Circuit Court of the State of Wisconsin, the Wisconsin Court of Appeals, the Wisconsin Supreme Court, and the Rules of Professional Conduct for Attorneys, if I am admitted pro hac vice; 9. That I have complied fully with the requirements of SCR Rule 10.03(4) applicable to me; 10. That I am applying for admission pro hac vice for the following reasons: I have applied for admission pro hac vice in the courts of the State of Wisconsin times previously in this calendar year. I certify that I am not required to pay a pro hac vice fee to the Office of Lawyer Regulation because I qualify for an exemption from the fee under SCR 10.03(4)(c) or (cm). Signature of Attorney Telephone Number Name Printed Address of Principal Office American LegalNet, Inc. www.FormsWorkFlow.com