Va. Sup. Ct. R. pt. 10, Form 1

IN THE SUPREME COURT OF VIRGINIA

REGISTRATION STATEMENT FOR LAWYER ENGAGING IN TEMPORARY

PRACTICE FOLLOWING DETERMINATION OF MAJOR DISASTER

Pursuant to Virginia Supreme Court Rule 10(f), the undersigned must complete the following

and file it with the Clerk of the Supreme Court of Virginia, 100 North 9th Street, 5th Floor,

Richmond, Virginia 23219 within 30 days of the commencement of the provision of legal

services. The attorney’s oath must be administered by a Judge or Justice of a court of

record.

1. Name

Lawyer’s full name.

Name of lawyer’s firm.

2. Home State Information

Lawyer’s residential address in home state.

Lawyer’s business address in home state.

Lawyer’s telephone number in home state.

Lawyer’s e-mail address.

3. Virginia Information

Lawyer’s residential address in Virginia.

Lawyer’s business address in Virginia.

Lawyer’s telephone number in Virginia.

Lawyer’s e-mail address.

4. Bar admission

List the courts before which you have been admitted to practice, the respective periods of

admission, and your registration or bar numbers.

Is your license to practice currently subject to disbarment, suspension, or restrictions in any

jurisdiction?

[] Yes [] No

If yes, explain the proceedings on a separate page and attach copies of all related documents.

5. Temporary Practice Following Determination of Major Disaster

(Check all that apply)

Specify whether you will engage in temporary practice pursuant to:

[] Virginia Supreme Court Rule 10(b) (pro bono legal services)

[] Virginia Supreme Court Rule 10(c) (legal services reasonably related to lawyer’s practice of

law in jurisdiction or area where the disaster occurred)

I agree that I am subject to the disciplinary authority of Virginia and the Virginia Rules of

Professional Conduct, as set forth in Rule 8.5 of the Virginia Rules of Professional Conduct.

[] Yes [] No

ATTORNEY CERTIFICATION

I certify under penalty of perjury and pursuant to the laws of the Commonwealth of Virginia

that the preceding is true and correct. I also certify under penalty of perjury that I have taken the

required attorney oath and have attached the motion and oath documents, signed by the Judge or

Justice of a court of record who administered the oath.

I certify under penalty of perjury and pursuant to the laws of the Commonwealth of Virginia

that I am licensed and in good standing and authorized to practice law in each jurisdiction listed

above and my license is not subject to suspension or restriction in any jurisdiction.

DATE SIGNATURE