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

[Note: the following form may be submitted electronically pursuant to Rule 1:17 and related

provisions of Virginia law.]

I, ........................................................................................................................., the undersigned attorney, hereby apply

NAME OF APPLICANT

to this tribunal of the Commonwealth of Virginia, ............................................................................., to appear as

NAME OF TRIBUNAL

Counsel pro hac vice pursuant to Rule 1A:4 of the Rules of the Supreme Court of Virginia.

I further state the following:

1. The case in which I seek to appear pro hac vice is styled

.............................................................., has docket number.......................................... and is pending in.................................

This case [] is [] is not a related or consolidated matter for which I have

previously applied to appear pro hac vice.

2. ..................................................................................................................................................................................................................................

APPLICANT’S RESIDENCE ADDRESS

APPLICANT’S OFFICE ADDRESS

3. ..................................................................................................................................................................................................................................

NAME OF LOCAL COUNSEL VSB NUMBER

STREET ADDRESS

FAX NUMBER EMAIL ADDRESS TELEPHONE NUMBER

4. ..................................................................................................................................................................................................................................

NAME OF PARTY TO CASE

NAME AND ADDRESS OF COUNSEL FOR PARTY

NAME OF PARTY TO CASE

NAME AND ADDRESS OF COUNSEL FOR PARTY

NAME OF PARTY TO CASE

NAME AND ADDRESS OF COUNSEL FOR PARTY

[] Additional Sheet attached.

5. ..................................................................................................................................................................................................................................

COURT TO WHICH APPLICANT IS ADMITTED DATE OF ADMISSION

COURT TO WHICH APPLICANT IS ADMITTED DATE OF ADMISSION

[] Additional Sheet attached.

6. I am a member in good standing and authorized to appear in the courts identified in

paragraph 5.

7. I am not currently disbarred or suspended in any state, territory, United States possession or

tribunal.

8. I [] am not [] am subject to a pendi ng disciplinary investigation or proceeding by any

court, agency or organization authorized to discipline me as a lawyer. (If such an

investigation or proceeding is pending, attach to this application and incorporate by reference

a statement specifying the jurisdiction, the nature of the matter under investigation or being

prosecuted, and the name and address of the disciplinary authority investigating or

prosecuting the matter.)

9. Within the past three (3) years, I [] have not [] have been disciplined by any court, agency

or organization authorized to discipline me as a lawyer. (If so, attach to this application and

incorporate by reference a statement specifying the name of the court, agency or organization

imposing discipline, the date(s) of such discipline, the nature of the complaint or charge on

which discipline was imposed, and the sanction.)

10. Within the last twelve (12) months preceding this application, I [] have not [] have sought

admission pro hac vice under this rule. (If so, attach to this application and incorporate by

reference a copy of the order of the tribunal granting or denying your previous application.

Such order(s) must include the name of the tribunal, the style of case and the docket number

for the case(s) in which you filed an application and whether the application was granted or

denied.)

[] Order(s) attached and incorporated by reference.

11. I hereby consent to the jurisdiction of the courts and agencies of the Commonwealth of

Virginia and of the Virginia State Bar and I further consent to service of process at any

address(es) required by this Rule.

12. I agree to review and comply with appropriate rules of procedure as required in the case for

which I am applying to appear pro hac vice.

13. I understand and I agree to comply with the rules and standards of professional conduct

required of members of the Virginia State Bar.

DATE SIGNATURE OF APPLICANT

Commonwealth/State of....................................................................................

[] City [] County of........................................................................................

Subscribed and sworn to/affirmed before me on this date by the above-named person.

DATE NOTARY PUBLIC

My commission expires: ...............................................