FORM FMC-12

 All questions must be fully answered . If additional space is

required, number items on plain white paper.

 I hereby apply for admission to practice before the Federal Maritime Commission, under the rules for the registration of persons entitled to practice before the

Commission, and submit the following:

 1. Name (Last, First, Middle Name or Initial)

 2. Business Address

 4. Are you a citizen of the United States? (Check one)

 Yes No

 5. Date of Birth 6. Place of Birth

7. EDUCATION

 (a) Name and location of high or preparatory schools Graduate

From To Yes No

 Dates Attended

 (b) Name and location of colleges attended

From To

Degrees

(if any)

 8. Present occupation and employment (Give dates)

 9. Other occupation and employment during the last 5 years (Give dates)

 FEDERAL MARITIME COMMISSION

APPLICATION FOR ADMISSION TO PRACTICE BEFORE THE

FEDERAL MARITIME COMMISSION

Dates Attended

 3. Residence Address

FORM FMC-12 (REV. 12-07)
FORM FMC-12 (REV. 12-07)

 10. (a) Have you ever previously applied for admission to practice before the Federal Maritime Commission ?

 (if "Yes," state when):

 (b) Have you been admitted to practice before any other department, bureau, or commission of the

 United States Government?.........................................................................................................................

 (if "Yes," state details):

 Yes No

 Yes No

 11. Have you been denied admission to practice, or been disbarred or suspended from practice before any

 court, department, bureau or commission of any State or the United States?.......................................................

 (if "Yes," explain fully):

 Yes No

 12. (a) Describe fully what steps you have taken to familiarize yourself with (1) the provisions of the Shipping Act of 1984 and other shipping statutes

 administered by the Commission; and (2) the decisions of the courts, and of the Commission and its predecessors, with respect to matters now under the

 jurisdiction of the Commission.

 (b) Describe fully your experience, if any, in conducting cases before other regulatory commissions, State or Federal.
FORM FMC-12 (REV. 12-07)

 13. State any additional facts to show that you have the necessary qualifications to render valuable services and are competent to advise and assist persons in

 proceedings before the Commission:

 14. Do you intend to engage:

 (a) In general practice before the Commission?......................................................................................................

 (b) For a company of which you are an officer or regular employee?.....................................................................

 (If "Yes" under (b), state name of company)

 Yes No

 Yes No

15. (a) Have you ever been employed by the Federal Maritime Commission or a predecessor agency?............................

 (b) If "Yes", state the following: Yes No

Position Held Date of Separation from Service Reason for Separation

Date of Appointment Reason for Separation

 (c) Have you ever been an employee of any other agency of the United States Government?.........................................

 (d) If, "yes", state the following:

Agency Date of Separation

 Yes No
FORM FMC-12 (REV. 12-07)

 16. Have you ever been a defendant in either a criminal prosecution or a proceeding based upon allegations of fraud?..........

 If "Yes", explain the circumstances and results:

 Yes No

 17. Give the name and business addresses of three persons, not relatives, who have knowledge of your experience, ability, and character. (Only one reference

 may be from a present business partner or associate.)

Full Name Business Address Business or Occupation

 "I declare under penalty of perjury that the statements in this application, to the best of my knowledge and belief, are true, correct, and complete."

 ____________________________________________ ______________________________________________________

 Date Signature of Applicant