Fill and Sign the Appearing for Form

Name:Law Firm: Address: Phone #: Appearing For: UNITED STATES DISTRICT COURT FOR THE DISTRICT OF ARIZONA ) )CASE NO. Plaintiff(s)/Petitioner(s),) ) vs.) ) Application of Attorney For Admission ) To Practice Pro Hac Vice ) Pursuant to Local Rule 1.5(b)(3) Defendant(s)/Respondent(s) ) NOTICE: Please submit the $25 fee with your application. I, , hereby apply to the Court under Local Rule 1.5(b)(3) for pro hac vice admission to appear and practice in this action on behalf of _______________________________________________________. RESIDENCE ADDRESS: CITY: STATE: ZIP: FIRM NAME: __________________________________________________________________________________________ ADDRESS: SUITE: CITY: STATE: ZIP: FIRM/BUSINESS PHONE: ( ) ________________________________________ I am admitted to practice before the following courts (attach additional sheets if necessary) TITLE OF COURT DATE OF ADMISSION IN GOOD STANDING (circle) __________________________________________ ____________________ Yes / No* __________________________________________ ____________________ Yes / No* __________________________________________ ____________________ Yes / No* (An Original Certificate of Good Standing from a FEDERAL BAR dated no more than 45 days prior to admission to this court is required.) I have concurrently, or within 1 year of this application, made pro hac vice applications to this Court in the following actions (attach additional sheets if necessary): CASE NUMBER TITLE OF ACTION DATE GRANTED OR DENIED* _____________________________________________________________ _________________________ ________________ _____________________________________________ _________________________ ______________________________________________________________ _________________________ *EXPLAIN: ________________________________________________________________________________ ___________________________________________________________________________________________ ALL APPLICANTS ARE REQUIRED TO ANSWER THE FOLLOWING QUESTIONS. If you answer YES to either of the following questions, please explain all circumstances on a separate page. Are you currently the subject of a disciplinary investigation or proceeding by any Bar or Court?Y/N Have you ever been disbarred from practice in any Court?Y/N I declare under penalty of perjury that the foregoing is true and correct; that I am not a resident of, nor am I regularly employed, engaged in business, professional or other activities in the State of Arizona; and that I am not currently suspended, disbarred or subject to disciplinary proceedings in any court. I have read and will ascribe to the Standards for Professional Conduct. __________________________________________________________________________________ DateSignature of Applicant(Rev. 9/99)