SCR ch. 10 app. A-2

STATE OF WISCONSIN, CIRCUIT COURT ______________COUNTY

CASE CAPTION: APPLICATION FOR ADMISSION

PRO HAC VICE

Under SCR 10.03(4)(c) or (cm)

Case Number:

I declare under penalty of perjury:

(1) That I seek to appear pro hac vice in order to represent

_______________________________ in the above-captioned matter;

(2) That I am nonresident military counsel seeking admission under SCR

10.03(4)(c) or nonresident counsel seeking to appear for the limited

purpose of participating in a child custody proceeding pursuant to the

Indian Child Welfare Act of 1978, 25 U.S.C. s. 1901, et seq., under SCR

10.03(4)(cm).

(3) That I am admitted to practice law in the highest court(s) of the state(s)

or country(ies) of ____________________________;

(4) That I am admitted to practice law before the court(s) of the following

federally recognized Indian tribes:

;

(5) That there are no disciplinary complaints filed against me for violation

of the rules of those courts (if so, please explain)

;

(6) That I am not suspended or disbarred from practice for disciplinary

reasons or reason of medical incapacity in any jurisdiction (if yes, please

explain) _

;

(7) That I do not practice or hold out to practice law in the State of

Wisconsin;

(8) That I acknowledge the jurisdiction of the courts of the State of

Wisconsin over my professional conduct, and I agree to abide by the

rules of the relevant division of the Circuit Court of the State of

Wisconsin, the Wisconsin Court of Appeals, the Wisconsin Supreme

Court, and the Rules of Professional Conduct for Attorneys, if I am

admitted pro hac vice;

(9) That I have complied fully with the requirements of SCR Rule 10.03(4)

applicable to me;

(10) That I am applying for admission pro hac vice for the following reasons:

.

I have applied for admission pro hac vice in the courts of the State of Wisconsin

_____ times previously in this calendar year.

I certify I am not required to pay a pro hac vice fee to the Office of Lawyer

Regulation because I qualify for an exemption from the fee under SCR 10.03(4)(c)

or (cm).

Signature: _______________________________________

Print Name:

Date:

Address:

Telephone Number:

Email Address (if any):