`
`United States District Court for Western District of Tennessee
`MOTION FOR LEAVE TO APPEAR PRO HAC VICE
`
`Revised July 2012
`
`Case Title
`Plaintiff
`
`Defendant
`
`Case Number
`
`Judge
`
`I, _______________________________________________________ hereby apply to the United
`States District Court for the Western District of Tennessee, pursuant to Local Rule 83.4(d), for
`permission to appear and participate in the above-entitled action on behalf of
`__________________________________________________ by whom I have been retained.
`
`I am a member of good standing and eligible to practice before the following courts:
`Title of Court
`Date Admitted
`
`I certify that I subject myself to the jurisdiction of the United States District Court for the
`Western District of Tennessee and have obtained and have familiarized myself with and agree
`to be bound by the Western District of Tennessee Local Rules, Tennessee Supreme Court Rule 8
`(Rules of Professional Conduct) and the Guidelines of Professional Courtesy and Conduct.
`
`Please find attached a certificate of good standing from the highest Court of a state or the
`District of Columbia, and from a United States District Court.
`
`A proposed order, in word processing format, granting this Motion will be emailed to the ECF
`mailbox of the presiding judge.
`
`The pro hac vice admission fee is $100.00 that shall be paid to the Clerk of Court through
`the Court’s Electronic Case Filing System’s pay.gov feature.
`
`Page -1-
`
`
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`Case 2:12-cv-02769-JPM-tmp Document 65 Filed 08/12/13 Page 2 of 2 PageID 465
`
`I hereby certify that the information provided below is true and accurate:
`Applicant’s Last Name
`First Name
`Middle Name/Initial
`
`Applicant’s Firm Name
`
`Applicant’s Address
`
`Room/Suite Number
`
`City
`
`State
`
`Zip Code
`
`Applicant’s Email Address
`
`Applicant’s Phone Number(s)
`
`Certificate of Service
`
`I hereby certify that a true and correct copy of the foregoing pleading has been served
`via the Court’s Electronic Case Filing system to the following:
`
`Certificate of Consultation
`
`Date
`
`Electronic Signature of Applicant
`
`S/
`
`Page -2-
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