Fill and Sign the E Services Electronic Attorney Registration Exemption Request Form

E-SERVICES ELECTRONIC ATTORNEY REGISTRATION EXEMPTION REQUEST JD-GC-18 New 6-06 Pr. Bk. Sec. 2-27(d),(e) STATE OF CONNECTICUT STATEWIDE GRIEVANCE COMMITTEE JUDICIAL BRANCH www.jud.ct.gov JURIS NUMBER 1. Type or print clearly. 2. File this form with the Statewide Grievance Committee at the below address no later than November 1st of the year preceding the year of the annual registration for which you are requesting an exemption. 3. You must submit a new request for exemption each year. 4. Keep a copy of this form for your records. REASON FOR EXEMPTION REQUEST ADDRESS OF ATTORNEY INSTRUCTIONS NAME OF ATTORNEY TO: Statewide Grievance Committee, 287 Main St., Second Floor, East Hartford, CT 06118-1885 (Tel. 860 568-5157) SIGNED (Attorney making request) X DATE SIGNED TELEPHONE NO. (Include area code) I hereby request an exemption from the requirement that I register electronically through E-Services to comply with the annual attorney registration pursuant to Practice Book § 2-27(d) and (e) for the following reason(s): I am requesting this exemption for (specify year): GRANTED. (You will receive a paper copy of your registration form. You will need to return the form by the date indicated on it in order to comply with Practice Book § 2-27(d) and (e).) DENIED. (You must register electronically through E-Services when notified by the Statewide Grievance Committee in order to comply with Practice Book § 2-27(d) and (e).) FOR STATEWIDE GRIEVANCE COMMITTEE USE ONLY - DO NOT WRITE BELOW THIS LINE SIGNED (Statewide/Assistant Bar Counsel) DATE SIGNED FILE DATE The Statewide Grievance Committee has considered this request and it is hereby: