Fill and Sign the Attorney Licensingvermont Judiciary Form

Vermont Pro Hac Vice Licensing Statement INSTRUCTIONS: This is a fillable form; to begin, click on a section, then tab to all other sections. Should you experience difficulty, you may print out this form and fill it in by hand. Fill out the form, print and notarize, keeping a copy for yourself. Mail this fully completed form with the appropriate fee to ATTORNEY LICENSING, 2418 Airport Road, Suite 2, Barre, VT 05641 with a Certificate of Good Standing from a licensing state or the District of Columbia. A separate licensing statement for each case must be completed. The fee for each licensing statement is $200. Checks should be made payable to ATTORNEY LICENSING. Please allow two weeks for processing. Questions should be directed to jud-attylicensing@state.vt.us Name: Office Address: City: State: Zip Code: Phone Number: Fax Number: Licensing State or DC Court: Date Admitted:Current Status: Upon acceptance of this application, you will be mailed a pro hac vice licensing card. Please allow two weeks for processing. The card shall be filed in the court in which the case is pending, along with a motion by a member of the Vermont Bar pursuant to V.R.C.P. 79.1(e), V.R.Cr.P. 44.2(b), V.R.F.P. 15(e), V.R.P.P. 79.1(d) or V.R.A.P. 45.1(e). Applicant Signature Dated this ______ day of _______________________, 20____. My Commission Expires Subscribed and sworn to before me this _____ day of __________________, 20____. Notary Public SignatureName of Case: Docket No.: Name of Sponsoring Vermont Attorney: Sponsor's Vermont License Number: I request that the fee be waived to enable me to represent an indigent client pro bono. Please attach a supporting statement. I understand that I must comply with and am subject to Vermont Statutes and Rules of the Vermont Supreme Court, including the Rules of Professional Conduct and the Rules Governing Establishment and Operation of the Professional Responsibility Program. Court: Email Address: By my signature, I certify that I am not suspended nor disbarred in any jurisdiction. I certify that I am in good standing and admitted to practice in the licensing state or DC court of: