Supreme Court of the United States
                                APPLICATION FOR ADMISSION TO PRACTICE

                                            PERSONAL STATEMENT

                                         TYPEWRITER SHOULD BE USED

Name                       (Type name as you want shown on your Certificate.)

Firm

Street

City & State                                                        Zip Code
                                                                  Check this box if you want the alternate
Office phone        A/C           No.                        MCertificate described in the instructions.
 1. Indicate city and state you want shown on your Certificate:

 2. Date of birth                                          3. Social Security No.

 4. Place of birth

 5. Residence address

 6. Names of parents: (a) Mother's maiden name
                            (b) Father's name

 7. State court(s) of last resort to which you are admitted to practice, and date(s) of admission.


 8. Are you engaged in the practice of the law?                              State the nature of your practice, whether by self, in
        partnership, or associated with or employed by others, giving the name of the firm or employer.



 9. List firms or other entities with which you have been formerly associated, or by which you have been employed, as a
        lawyer.



10. State extent of undergraduate and legal education and when and where degrees received.



11. Have you ever changed your name or been known by any name or surname other than those appearing on this
        application?                       If so, state and give details.



12. (a) Have you ever been disciplined, disbarred, or suspended from practice before any court, department, bureau,
            or commission of any State or the United States, or have you received any public or private reprimands from
            any such court, department, bureau, or commission pertaining to your conduct or fitness as a member of the
            bar?                  If so, answer in detail on an attached separate statement.
        (b) Are there any such proceedings presently pending against you?




                                         COMPLETE CERTIFICATE ON REVERSE



                                                         CERTIFICATION

I certify that I have read the foregoing questions and have answered them fully and frankly. The answers are complete and
are true to my own knowledge.

Dated this              of

                                                                                       (Signature of applicant)
                      , 20            .

                                                 STATEMENT OF SPONSORS
                                                           (Type or Print)

We,                                                                                                                                and

                                                                                                                   , being members of
the Bar of the Supreme Court of the United States and not related to the applicant, state that the applicant is personally
known to us, that the applicant possesses all the qualifications required for admission to the Bar of the Supreme Court of the
United States, and that we have examined the applicant's personal statement and believe it to be correct, and we affirm that
the applicant's moral and professional character and standing are good.

(Signature)                                                        (Signature)

(Office address)                                                   (Office address)



                    COMPLETE THE FOLLOWING ONLY IF ADMISSION IS ON WRITTEN MOTION

                                                   MOTION FOR ADMISSION

              (Movant's name is to be entered below as it appears on movant's Certificate of Admission to this Court.)

       I,                                                                                   , a member of the Bar of the Supreme
                                                (Type or Print)
Court of the United States, hereby move the admission of
to the Bar of the Supreme Court. I am satisfied the applicant possesses the necessary qualifications.


                                                                                                  (Signature)


                                                   OATH OF ADMISSION

       I,                                                                                           , do solemnly swear (or affirm)
that as an attorney and as a counselor of this Court I will conduct myself uprightly and according to law, and that I will support
the Constitution of the United States.


                                                                                            (Applicant's Signature)
Subscribed and Sworn to
before me this
day of                        , 20         .                                                    (Notary Public)


(This oath shall be sworn to before a Notary Public, or any other person authorized to administer oaths, and the seal affixed).



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