SCR ch. 10 app. B

STATE OF WISCONSIN

SUPREME COURT

In-House Counsel Registration

I, ________________________________, request to be registered as in-house

counsel for ___________________________, a corporation, association, or other

nongovernmental entity with an office in Wisconsin pursuant to Wisconsin

Supreme Court Rules 20:5.5(d)(1) and SCR 10.03(4).

Wisconsin address of corporation/entity:

Wisconsin telephone number:

I declare under penalty of perjury that:

(1) I am employed as a lawyer by the above-named corporation/entity and that

my employment conforms to the requirements of SCR 10.03 (4) (f).

(2) The above corporation, association or non-governmental entity is in good

standing with the state of Wisconsin.

(3) I am admitted to practice law in the following jurisdictions,

________________________________, without any restriction on my eligibility

to practice law. I understand my obligation to notify this court immediately of any

change respecting the status of my license to practice law in any jurisdiction in

which I am licensed to practice law.

(4) I acknowledge that I am subject to the Wisconsin Supreme Court Rules,

including the Rules of Professional Conduct for Attorneys.

(5) I understand that, as a registered in-house counsel, I am permitted to

practice law in Wisconsin but only on behalf of the corporation, association or non-governmental entity for which I am employed, its directors, officers, and employees

in their respective official or employment capacities, and/or its commonly owned

or controlled organizational affiliates. I understand that I shall not appear in the

courts of Wisconsin or in any agency or municipal proceeding that I have reason to

believe prior to the proceeding is contested, unless pro hac vice admission is

required and I am admitted pro hac vice pursuant to SCR 10.03(4).

I attach hereto the documents required by SCR 10.03 (4) (f).

I attach hereto evidence of my payment of the annual in-house counsel registration

fee to the Board of Bar Examiners.

_________________________________________________

Signature

_________________________________________________

Print Name

______________________________

Date

Address and Telephone Number