900-00022 - Vermont Pro Hac Vice Licensing Statement (05/2017) Page 1 of 1
Vermont Pro Hac Vice Licensing Statement
INSTRUCTIONS: To apply for a Vermont Pro Hac Vice License, send this completed form, original Certificate of Good
Standing from a licensing state or District of Columbia and check made payable to ATTORNEY LICENSING to
Attorney Licensing
32 Cherry Street, Suite 213
Burlington, VT 05401
You must complete a separate Licensing Statement for each case.
The fee for each Licensing Statement is $200. Please allow two weeks for processing.
Questions should be directed to jud.attylicensing@vermont.gov
Name: __________________________________________________________________________
Office Address: __________________________________________________________________________
City: ___________________________ State: _____________ Zip: ________________
Phone: ___________________________ Fax: _______________ Email: _______________________
Licensing State
or DC Court: _________________________ Date Admitted: _______ Current Status: ________________
Name of Docket
Case: _______________________________ Number: _____________ Court: _______________________
Name of Sponsoring Vermont Attorney: _________________________________________________________
Sponsoring Attorney’s License Number: _________________________________________________________
☐ I request that the fee be waived to enable me to represent an indigent client pro bono. (Attach supporting statement)
By my signature, I certify that I am not suspended nor disbarred in any jurisdiction. I certify that I am in good
standing and admitted to practice in the licensing state or DC court of: _______________________________.
I understand that I must comply with and am subject to Vermont Statutes and Rules of the Vermont Supreme Court,
including the Rules of Professional Conduct and the Rules Governing Establishment and Operation of the
Professional
Responsibility Program.
Date: _____________ Applicant’s Signature: _____________________________
Subscribed and sworn to before me:
Date: _____________ Notary Public Signature: ________________________ My Commission Expires: __________
Upon acceptance of this application, the pro hac vice licensing card will be mailed to the sponsoring attorney, unless
directed
otherwise. The card shall be filed in the court in which the case is pending, along with a motion by the
sponsoring member of the
Vermont Bar pursuant to V.R.C.P. 79.1(e), V.R.Cr.P. 44.2(b), V.R.F.P. 15(e), V.R.P.P.
79.1(d) or V.R.A.P. 45.1(e).
