Pro Hac Vice Admission Form

PENNSYLVANIA IOLTA BOARD
Form for PRO HAC VICE ADMISSION

(For all nonresident attorneys requesting permission to participate in proceedings in a Pennsylvania Court)
Note: * Denotes a required field.

Applicant Name:*	Mr.Ms.
		* Last	* First	Middle

		* Date of Birth

Your Firm's Name & Mailing Address:

* Firm Name

* Street / P.O. Box Ste. No.	Address 2	Address 3


* City	* State	* Zip Code	* Country

Ext.
* Office Phone	* Office Fax

Your Firm's Physical Address: Check here if same as above

* Street Ste. No.	Address 2	Address 3


* City	* State	* Zip Code	* Country

Acknowledgement Letter should be provided to:
			FaxE-Mail
* Contact Name	Contact Fax	Contact E-Mail	* Delivery Preference

Name & Office Address of Attorney of Record in the Pennsylvania Proceeding who is filing the Motion for your admission Pro Hac Vice:

* PA I.D. Number If you do not know the PA I.D. Number, you may obtain it from the PA Disciplinary Board’s website at www.padisciplinaryboard.org

* Name		Firm Name

* Street/P.O. Box Ste. No.	Address 2	Address 3


* City	* State	* Zip Code

Ext.
Office Phone		Office Fax
		FaxE-Mail
Sponsor's E-Mail		* Delivery Preference

* My application is being submitted for a consolidated case: YesNo

Please attach the corresponding consolidation order using the upload button below. Additionally, enter only the lead case name and docket number from the consolidated cases in the case information section below.

Select a file from your computer to upload and attach to your application form (Accepted file-types are .zip, .txt, .csv, .xls, .xlsx, .pdf, .doc, .docx. The uploaded file(s) must be less than or equal to 10 MB in size):

Current Uploads:

Add one or more cases by using the link below:
(The fee is calculated per attorney per case.)

* Add Case Information

List all foreign, state and federal jurisdictions in which you have been qualified, licensed or admitted to practice law and are currently active and in good standing, the year of licensure, and your license or bar card numbers, if applicable.

Primary Jurisdiction:
* Jurisdiction:	* *Year of Licensure:	* License Number: If you do not know your license number, contact the attorney registrar in the state where you are licensed. The application can only take numerical values. It cannot take letters or symbols.
		check if this Jurisdiction does not enter a license #

Other Jurisdictions:

Add Another Jurisdiction

If you have ever practiced law under another name, please state that name here. List also all jurisdictions in which you practiced law under that name, license number, and the time period involved.

Add Name

* Are you familiar with the Pennsylvania Rules of Professional Conduct, Pennsylvania Rules of Disciplinary Enforcement, and the rules and court procedures of the court before which you seek to appear, and will you at all times abide by and comply with the same so long as such Pennsylvania proceeding is pending and you have not withdrawn as counsel therein?

YesNo

* My client is proceeding in forma pauperis: YesNo

Please attach the Motion to proceed in forma pauperis or the Order granting the motion:

Select a file from your computer to upload and attach to your application form (Accepted file-types are .zip, .txt, .csv, .xls, .xlsx, .pdf, .doc, .docx. The uploaded file(s) must be less than or equal to 10 MB in size):

Current Uploads:

* I certify that the information provided on this form is true. If any statements are false, I realize I am subject to discipline by the Supreme Court of Pennsylvania. I hereby certify that I am enclosing the fee required by Rule 301 of the Pennsylvania Bar Admission Rules. I hereby agree that no refunds will be issued under any circumstances, pursuant to 204 Pa Code § 81.505.(a). I hereby agree that any action brought against me by the Supreme Court of Pennsylvania or any of its boards or instrumentalities may be brought in the Court of Common Pleas of Allegheny, Dauphin or Philadelphia County, Pennsylvania.

Signature

* Type the Applicant's Full Name in the box above.

* Date of Application

Please press "submit" only once. In order to prevent duplicates, pressing "submit" repeatedly will trigger a security measure that stops the payment and submission of the application. If you receive an error message, please wait 5-10 minutes before attempting to complete and submit the application again.

* Jurisdiction:
* Year of Licensure:
License #:

* Jurisdiction:
* Year of Licensure:
License #:

* Name:
* Jurisdiction:
License #'s:
* Time Period:

* Name:
* Jurisdiction:
License #'s:
* Time Period:

* Case #:
* Case Name:
Term:
* PA Court:
Locations(Judicial District):

* Case #:
* Case Name:
Term:
* PA Court:
Locations(Judicial District):

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Pennsylvania IOLTA Board