Microsoft Word pro hac vice form doc

---

 

 

A

PPLICATION TO 

A

PPEAR 

P

RO 

H

AC 

V

ICE 

B

EFORE A 

V

IRGINIA 

T

RIBUNAL

 

I,                                                                           

,  the 

APPLICANT FIRST NAME                        MIDDLE NAME                             LAST NAME                           SUFFIX

undersigned attorney, hereby apply to this tribunal of the Commonwealth of Virginia, 

 

, to appear as 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. 

 I have previously applied to appear pro hac vice in the following related or 

consolidated matters:  

a.   

 

DOCKET NUMBER                             

   COURT NAME    

               

   

          

  DATE OF PRO HAC  

                                                                                                                                     

       VICE APPLICATION 

STYLE OF RELATED OR CONSOLIDATED MATTER 

b.  

DOCKET NUMBER   

                      

   COURT NAME       

   

                           

   

  DATE OF PRO HAC  

                                        

      

   

     VICE APPLICATION 

 

                               

STYLE OF RELATED OR CONSOLIDATED MATTER 

 Additional Sheet attached.

 

 

.

APPLICANT’S RESIDENCE

2.    

     

APPLICANT’S OFFICE ADDRESS 

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

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

1 of 4 

Clear All Data

 

 

 

 

 

---

 

 

 

 

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 

BAR # 

          COURT TO WHICH APPLICANT IS ADMITTED 

 

DATE OF ADMISSION 

BAR # 

 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. 

2 of 4

 

 

---

8. I        am not   subject to a pending disciplinary investigation or proceeding by  

          am subject to a pending 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 been disciplined

 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 sought admission pro hac vice under this rule. 

      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. 

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. 

3 of 4

---

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:  ..................................  

   

 

4 of 4