2017SeptCertCopyApp
Commonwealth of Massachusetts
SUFFOLK, SS. SUPREME JUDICIAL COURT
Request
for Certified Copy of Petition for Admission
Attorney/Petitioner Name:
Last: __ ___ First: ___________________________ Middle: ____________
Mailing Address:
(Delivery Address for the certified copy of the Petition(s))
Address 1: _____
Address 2:
City: ____________________________ State: __________ Zip: __________ Zip Ext.: __________
Contact for the Request
(if different than the Petitioner/Attorney):
Name: ______________________________________________________________________________
Ful
l Address: _________________________________________________________________________
(i.e. Example Building, 123 Example ST., Ste., 1111; Pretend City, ST 02134)
Contact Number: Email:
Has the Petitioner/Attorney ever been known by any other name? Yes: _____ No: _____
If yes, provide former name information:
Previous Last: First: Middle:
If applicable, when did the Petitioner/Attorney take the Massachusetts Bar?
(mm/dd/yyyy)
If applicable, what is the date of admission to the Massachusetts Bar?
(mm/dd/yyyy)
If applicable, what is the registered BBO Number? ___________________________________
Why are you requesting the certified copy of the Petition(s) for Admission?
(i.e. Admission to another jurisdiction, etc.)
Signed under the pains and penalties of perjury. Massachusetts General Laws, Chapter 268, section 1A*
Signed: Dated:
No written statement required by law shall be required to be verified by oath or affirmation before a magistrate if it contains or is verified by a written declaration
that is made under the penalties or perjury. Whoever signs and issues such a written statement containing or verified by such a written declaration shall be
guilty of perjury and subject to the penalties thereof if such statement is willfully false in a material matter.
