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Rule 31.25 — Form 1 : Application for Admission Pro Hac Vice -- District Court January 201 7 Rule 31.25 — Form 1 Page 1 of 4 Iowa District Court for County County where your case is filed Plaintiff( s) Full name: first, middle, last vs. Defendant (s) Full name: first, middle, last Case no. Application for Admission Pro Hac Vice -- District Court Iowa Court Rule 31.14 1. Application The undersigned seeks permission to appear pro hac vice in the above - captioned proceeding. Applicant must complete all of the following: If this matter involve s review of an agency action , did the applicant seek admission pro hac vice in the proceedings below?  Yes  No If yes, attach copies of all related documents. a . Applicant's full name, residential address, email address, and business address. Full name: first, middle, last Email address Mailing address City State ZIP code Business address City State ZIP code b. The name, address, and tele phone number of each client to be represented. c. The courts before which the applicant has been admitted to practice and the respective periods of admission and any jurisdiction in which the out - of - state lawyer has been licensed to practice as a foreign legal consultant and the respective period of licensure. d. Has the applicant ever been denied admission pro hac vice in this state?  Yes  No Rule 31.25 —Form 1 : Application for Admission Pro Hac Vice --District Court , continued January 201 7 Rule 31.25 —Form 1 Page 2 of 4 If yes, on a separate page specif y the caption of the proceedings, the date of the denial, and what findings were made. Attach copies of all related documents. e. Has the applicant ever had admission pro hac vice revoked in this state?  Yes  No If yes, on a separate page specify the caption of the proceedings, the date of the denial, and what findings were made. Attach copies of all related documents. f. Has the applicant ever been denied admission in any jurisdiction for reasons other than failure of a bar examination?  Yes  No If yes, on a separate page specify the caption of the proceedings, the date of the denial, and what findings were made. Attach copies of all related documents. g. Has the applicant ever been formally disciplined or sanctioned by any court in this state?  Yes  No If yes, on a separate page specify the nature of the allegations, the name of the authority bringing such proceedings, the caption of the proceedings, the date filed, what findings were made, and what action was taken in connection with those proceed ings. Attach copies of all related documents. h. Has the applicant ever been the subject of any injunction, cease -and -desist letter, or other action arising from a finding that the applicant engaged in the unauthorized practice of law in this state or els ewhere?  Yes  No If yes, on a separate page specify the nature of the allegations, the name of the authority bringing such proceedings, the caption of the proceedings, the date filed, what findings were made, and what action was taken in connection with those proceedings. Attach copies of all related documents. i. Has any formal, written disciplinary proceeding ever been brought against the applicant by a disciplinary authority or unauthorized practice of law commission in any other jurisdiction wit hin the last five years?  Yes  No If yes, on a separate page specify as to each such proceeding: the nature of the allegations, the name of the person or authority bringing such proceedings, the date the proceedings were initiated and finally concluded, the style of the proceedings, and the finding s made and actions taken in connection with those proceedings. Attach copies of all related documents. j. Has the applicant ever been placed on probation by a disciplinary authority in any other jurisdiction?  Yes  No If yes, on a separate page spec ify the jurisdiction, caption of the proceedings, the terms of the probation, and what findings were made. Attach copies of all related documents. k. Has the applicant ever been held formally in contempt or otherwise sanctioned by any court in a written o rder in the last five years for disobedience to the court’s rules or orders?  Yes  No If yes, on a separate page specify the nature of the allegations, the name of the court before which such proceedings were conducted, the date of the contempt orde r or sanction, the caption of the proceedings, and the substance of the court's ru lings. Attach to this application a copy of the written order or a transcript of the oral ruling and other related documents. l. Has the applicant filed an application to ap pear pro hac vice in this state within the preceding two years?  Yes  No Rule 31.25 —Form 1 : Application for Admission Pro Hac Vice --District Court , continued January 201 7 Rule 31.25 —Form 1 Page 3 of 4 If yes, on a separate page list the name and address of each court or agency and a full identification of each proceeding in which an application was filed, including the date and outcome of the application. Attach copies of all related documents. m. The applicant acknowledges familiarity with the rules of professional conduct, the disciplinary procedures of this state, the standards for professional conduct, the applicable local rules, and the procedures of the court before which the applicant seeks to practice.  Yes  No n. List the name, address, telephone number, email address, and personal identification number of an in -state lawyer in good standing of the bar of th is state who will sponsor the applicant's pro hac vice request. Lawyer’s name PIN Email address Lawyer’s address City State ZIP code o. The applicant acknowledges that service upon the in -state attorney in all matters connected with the proceedings will have the same effect as if personally made upon the applicant.  Yes  No p. If the applicant has appeared pro hac vice in this state in five proceedings within the preceding two years, the applicant must, on a separate attached page, provide a statement showing good cause why the applicant should be admitted in the present proceeding. q. On a separate attached page the applicant must provide any other information the applicant deems necessary to support the application for admission pro hac vice. r. Has the applicant registered with the office of professional regulation and paid the fee as required by Iowa Court Rule 31.14(11) within five years of the date of this application?  Yes  No Lawyer’s Oath and Signature and Certificate of Service on next page Rule 31.25 — Form 1 : Application for Admission Pro Hac Vice -- District Court , continued January 201 7 Rule 31.25 — Form 1 Page 4 of 4 2. Oath and Signature I, , have read this Application, and I certify under Print your name penalty of perjury and pursuant to the laws of the State of Iowa that the preceding is true and correct. , 20 Signed on: Month Day Year Your signature* Mailing address City State ZIP code ( ) Telep hone number Email address Additional email address, if applicable * If fili n g i n p ap e r, y o u m u st h a n d write y o u r si g n a t u re o n t h is f o r m . If fili n g e le c tro n ic a ll y , you may handwrite your signature on the form, s c a n t h e f o rm , and then file it electronically, or, you may affix a digitized signature and file the form el ec tro n icall y . Certificate of Service The undersigned certifies a copy of this application was served on the following parties : on the day of , 20 Month Year by  Personal delivery Deposit in the U.S. mail Signature of server