Fill and Sign the Civilcriminal No Form

IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF WEST VIRGINIA Plaintiff(s), v. (CIVIL)(CRIMINAL) NO: Defendant(s) . APPLICATION FOR ADMISSION PRO HAC VICE Pursuant to the Local Rule of General Practice and Procedure 83.2, I verify that I have fully complied with that rule as it relates to admission to practice pro hac vice. Applicant’s Name Representing (Party Name) Name of Firm Office Address Office Telephone Number Office Fax Number Name, Address, and Telephone Numbers of State Bars in which admitted: All matters before West Virginia tribunals or bodies in which the applicant is or has been involved in the preceding twenty-four (24) months: PROVIDE ATTACHMENT WITH ADDITIONAL INFORMATION IF NECESSARY All matters before West Virginia tribunals or bodies in which any member of applicant’s firm, partnership or corporation is or has been involved in the preceding twenty-four (24) months: PROVIDE ATTACHMENT WITH ADDITIONAL INFORMATION IF NECESSARY I certify that the foregoing application is true and correct. I hereby represent that I am a member in good standing with the bar of every jurisdiction in which I am admitted and my privileges to practice law and my membership in any bar association have never been amended, modified, suspended, revoked or otherwise limited in any way in any court, district, state, commonwealth or other jurisdiction. I also certify that I have never been convicted of a felony. I agree to comply with all laws, rules, and regulations of the United States Courts where applicable. I further certify that I have submitted with this application, the requisite fee of Fifty Dollars ($50.00) pa yab le to th e C lerk of the Court of the United States District Court for the Northern District of West Virginia. Signature of Applicant Name of Responsible Local Attorney Name of Firm Office Telephone Number Office Address Pursuant to Local Rule of General Practice and Procedure 83.2, I have read the foregoing application and, by my endorsement hereon, agree to be a responsible local attorney in the above- styled matter. I further certify that I am an active member in good standing of the West Virginia Bar and that I maintain an actual office in West Virginia from which I practice law on a daily basis. Signature of Responsible Local Attorney O R D E R Upon consideration of the foregoing Application for Admission Pro Hac Vice, it is ORDERED that the Application for Admission Pro Hac Vice be, and the same is hereby, APPROVED and that the applicant may appear pro hac vice in this matter on behalf of the represented party. ENTER: United States District Judge