BTXN 104a (rev. 09/19)

UNITED STATES BANKRUPTCY COURT

NORTHERN DISTRICT OF TEXAS

In Re:

Debtor(s)

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Case No.:

APPLICATION FOR ADMISSION PRO HAC VICE

1. Name: ________________________________________________________________

 Last First MI

2. Firm Name: ____________________________________________________________

3. Address: ______________________________________________________________

 ______________________________________________________________

 ______________________________________________________________

4. Phone: ____________________________ FAX: _____________________________

Email: ______________________________________

5. Name used to sign all pleadings: ___________________________________________

6. Retained by: ___________________________________________________________

7. Admitted on __________________________ and presently a member in good standing

of the bar of the highest court of the state of __________________________________

and issued the bar license number of __________________________ .

8. Admitted to practice before the following courts:

Court: Admission Date:

____________________________________ _________________________

____________________________________ _________________________

____________________________________ _________________________

Continued.

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9. Are you presently a member in good standing of the bars of the courts listed above?

 Yes No

If “No,” please list all courts which you are no longer admitted to practice: 

10. Have you ever been subject to a grievance proceeding or involuntary removal proceeding

while a member of the bar of any state or federal court?

 Yes No

If “Yes,” please provide details: 

11. Other than minor traffic offenses, have you ever been charged, arrested, or convicted of a

criminal offense or offenses?

 Yes No

If “Yes,” please provide details: 

12. Please list all cases in the United States Bankruptcy Court, Northern District of Texas in

which you have filed for pro hac vice in the past three years:

Date of Application Case No. and Style

__________________ _______________________________________________

__________________ _______________________________________________

__________________ _______________________________________________

13. Local counsel of record: ___________________________________________________

14. Local counsel’s address: ___________________________________________________

_______________________________________________________________________

Continued.

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I respectfully request to be admitted to practice in the United States Bankruptcy Court for

the Northern District of Texas for this cause only.

I certify that I have read Dondi Properties Corp. v. Commerce Savs. & Loan Ass’n, 121

F.R.D. 284 (N.D. Tex. 1988) (en banc), and the local civil and bankruptcy rules of this court and

will comply with the standards of practice adopted in Dondi and with the local civil and

bankruptcy rules.

 I am an ECF filer. I also certify that I have served a true and correct copy of this

document upon each attorney of record and filed the application via ECF with the payment of

$100.00

 I am not an ECF filer. I also certify that I have served a true and correct copy of this

document upon each attorney of record and the original upon the US Bankruptcy Court

accompanied with the $100.00 filing fee on ________________. 

_______________________________ ____________________

Printed Name of Applicant Date

_____________________________

Signature of Applicant

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