______________________________________ 

UNITED STATES DISTRICT COURT

DISTRICT OF OREGON

Civil Case No. ____________ 

____

v.

_____________________________ 

Plaintiff(s), 

_____ APPLICATION FOR SPECIAL 

ADMISSION – PRO HAC VICE 

Defendant(s). 

Attorney requests special admission pro hac vice in 

the above-captioned case. 

Certification of Attorney Seeking Pro Hac Vice Admission: I have read and understand the 

requirements of LR 83-3, and certify that the following information is correct: 

(1) PERSONAL DATA:

Name: 

(Last Name) 

Firm or Business Affiliation: 

(First Name) (MI) (Suffix) 

Mailing Address: 

City: 

Phone Number: 

State: 

 Fax Number: 

Zip: 

Business E-mail Address:

U.S. District Court–Oregon Application for Special Admission - Pro Hac Vice 

Revised March 1, 2014 Page 1 of 3

Case 3:14-cv-00706-YY Document 7 Filed 04/29/14 Page 1 of 3
(2) BAR ADMISSIONS INFORMATION:

(a) State bar admission(s), date(s) of admission, and bar ID number(s): 

(b) Other federal court admission(s), date(s) of admission, and bar ID number(s): 

(3) CERTIFICATION OF DISCIPLINARY ACTIONS: 

(a) ܆ I am not now, nor have I ever been subject to any disciplinary action by any 

state or federal bar association; or

(b) ܆ I am now or have been subject to disciplinary action from a state or federal bar 

association. (See attached letter of explanation.) 

(4) CERTIFICATION OF PROFESSIONAL LIABILITY INSURANCE: 

I have professional liability insurance, or financial responsibility equivalent to liability 

insurance, that will apply and remain in force for the duration of the case, including any 

appeal proceedings. 

(5) REPRESENTATION STATEMENT:

I am representing the following party(s) in this case: 

U.S. District Court–Oregon Application for Special Admission - Pro Hac Vice 

Revised March 1, 2014 Page 2 of 3

Case 3:14-cv-00706-YY Document 7 Filed 04/29/14 Page 2 of 3
(6) CM/ECF REGISTRATION: 

Concurrent with approval of this pro hac vice application, I acknowledge that I will 

become a registered user of the Court's Case Management/Electronic Case File system. 

(See the Court's website at ord.lIscoUlis.gov), and I consent to electronic service pursuant 

to Fed. R. Civ. P 5(b)(2)(E) and the Local Rules of the District of Oregon. 

DATED this ____ day of_A--=p_r_il ____ 2_0_14 __ _ 

(Signatllre of Pro Hac COl/nse!) 

Nina Wasow 

(Typed Name) 

CERTIFICATION OF ASSOCIATED LOCAL COUNSEL: 

I certify that I am a member in good standing of the bar of this Court, that I have read and understand the 

requirements of LR 83-3, and that I will serve as designated local counsel in this particular case. 

DATED this ____ day of--=A..::.lpc:c:r.::.:il ___ , _2_0_14 __ _ 

Name: Dejong 

(Last Name) 

s/Timothy S. Dejong 

(Signatllre of Local Counsel) 

Timothy 

(First Name) 

S. 

(MJ) (Suffix) 

Oregon State Bar Number: _94_0_6_6_2 _______________________ _ 

Firm or Business Affiliation: Stoll Stoll Berne Lokting & Shlachter P.C. 

Mailing Address: 209 S.W. Oak St., Suite 500 

City: Portland State: OR Zip: _9_72_0_4 __ _ 

Phone Number: (503) 227-1600 Business E-mail Address: (503) 227-6840 

COURT ACTION 

D Application approved subject to payment of fees. 

D Application denied. 

DATEDthis ____ dayof ___________ _ 

u.s. District Court-Oregon 

Revised March 1,2014 

Judge 

Application for Special Admission - Pro Hac Vice 

Page 3 of3 

Case 3:14-cv-00706-YY Document 7 Filed 04/29/14 Page 3 of 3