United States District Court Northern District of Illinois 

MOTION FOR LEAVE TO APPEAR PRO HAC VICE 

Case Title: 

VS. 

Plantiff(s) 

Defendant(s) 

Case Number: Judge: 

I, hereby apply to the Court 

under Local Rule 83.14 for permission to appear and participate in the above-entitled action on behalf of 

by whom I have been retained. 

I am a member in good standing and eligible to practice before the following courts: 

Title of Court Date Admitted 

I have currently, or within the year preceding the date of this application, made pro hac vice applications to this 

Court in the following actions: 

Case Number Case Title 

Date of Application 

(Granted or Denied)* 

 

*If denied, please explain: 

(Attach additional form if 

necessary) 

Pursuant to Local Rule 83.15(a), applicants who do not have an office within the Northern District of Illinois must designate, at the 

time of filing their initial notice or pleading, a member of the bar of this Court having an office within this District upon who service of 

papers may be made. 

Has the applicant designated local counsel? Yes No 

If you have not designated local counsel, Local Rule 83.15(b) provides that the designation must be made within thirty (30) days. 

Yitzchok Rokowsky

Vericity, Inc., et al.

1:20-cv-00456 Honorable Andrea R. Wood

Raina C. Borrelli

Plaintiff Yitzchok Rokowsky

District of Minnesota 11/08/2011

X

Case: 1:20-cv-00456 Document #: 36 Filed: 06/08/20 Page 1 of 2 PageID #:246
Has the applicant ever been: 

sanctioned, censured, suspended, disbarred, or otherwise disciplined by 

any court? 

or is the applicant currently the subject of an investigation of the 

applicant’s professional conduct? 

transferred to inactive status, voluntarily withdrawn, or resigned from the 

bar of any court? 

denied admission to the bar of any court? 

Yes No 

Yes No 

Yes No 

Yes No 

held in contempt of court? Yes No

NOTE: If the answer to any of the above questions is yes, please attach a brief description of the incident(s) and the applicant’s current 

status before any court, or any agency thereof, where disciplinary sanctions were imposed, or where an investigation or investigations 

of the applicant’s conduct may have been instituted. 

I have read the Rules of Professional Conduct for the Northern District of Illinois and the Standards for Professional Conduct within 

the Seventh Federal Judicial Circuit, and will faithfully adhere to them. I declare under penalty of perjury that the foregoing is true and 

correct. 

S/ 

Date Electronic Signature of Applicant 

Applicant’s Name 

Applicant’s Law Firm 

Last Name First Name Middle Name/Initial 

Applicant’s Address 

Street Address Room/Suite Number 

City State ZIP Code Work Phone Number 

Email Address

(The pro hac vice admission fee is $150.00 and shall be paid to the Clerk. No admission under Rule 83.14 is effective until such 

time as the fee has been paid.) 

NOTE: Attorneys seeking to appear pro hac vice may wish to consider filing a petition for admission to the general bar of this Court. The 

fee for admission to the General Bar is $181.00 The fee for pro hac vice admission is $150.00. Admission to the general bar 

permits an attorney to practice before this Court. Pro hac vice admission entitles an attorney to appear in a particular case 

only. Application for such admission must be made in each case; and the admission fee must be paid in each case. 

Rev. 11/13/2019 

X

X

X

X

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06/08/2020 Raina C. Borrelli

Borrelli Raina C.

Gustafson Gluek PLLC

120 South 6th Street 2600

Minneapolis MN 55402

(612) 333-8844

rborrelli@gustafsongluek.com

Case: 1:20-cv-00456 Document #: 36 Filed: 06/08/20 Page 2 of 2 PageID #:247