900-00006 – Attorney Certification of Compliance with Rule 12(a)(2) (07/2016) Page 1 of 1
Attorney Certification of Compliance with Rule 12(A)(2) of the Rules of Admission
You must complete this form if you applied for admission by examination or by transferred UBE score.
Contact Information
1. Last name:
2. First name:
3. Attorney License Number:
4. Email address:
5. Date of Admission:
6. Supervising Attorney or Judge:
By signing and submitting this form, I understand that I am certifying each of the following:
I completed the mentorship required by Rule 12(A)(2) of the Rules of Admission.
I did so under the supervision of an attorney or judge who had been admitted to the Bar of the Vermont
Supreme Court for at least 3 years when my mentorship began.
The mentorship lasted at least 6 months, during which I met with my supervising attorney or judge no less
than 10 times to discuss my practice and issues relevant to Vermont practice and procedure.
During the mentorship I engaged in at least 40 hours of activities on the mentorship program list compiled
by the Board of Continuing Legal Education and certified by the Board of Bar Examiners as satisfying the
requirements of Rule 12(A)(2) of the Rules of Admission.
I have completed and included a certification of mentorship program activities list that truthfully and
accurately reflects the activities in which I engaged.
I completed all activities required under Rule 12(A)(2) within 1 year of the date of my admission.
I will keep records demonstrating compliance with Rule 12(A)(2) for two years from the date of signing this
form and make them available to the Attorney Licensing Office upon request.
I understand that I am submitting this form in connection with my application for admission to the Bar of
the Vermont Supreme Court and subject to the provisions of the Vermont Rules of Professional Conduct,
including Rule 8.1(a).
Date: _______________________________
Signature: ______________________________
