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1 OFFICE OF THE CLERKPATRICIA S. DODSZUWEIT UNITED STATES COURT OF APPEALS TELEPHONE CLERK FOR THE THIRD CIRCUIT 215-597-299521400 UNITED STATES COURTHOUSE 601 MARKET STREET PHILADELPHIA 19106-1790 Website: http://www.ca3.uscourts.gov ATTORNEY ADMISSION RENEWAL / ADJUSTMENT OF STATUS FORM Pursuant to Rule 17 of the Rules of Attorney Disciplinary Enforcement (223R.A.D.E.224) (effective July 1, 2015), this form must be completed by: (1) attorneys admitted to practice before the bar of the Court of Appeals for the Third Circuit who have not entered an appearance within the past five years; and (2) attorneys requesting to adjust their status. All applicants filing this form must complete Section I in its entirety. Section II through V should be completed where applicable. The completed form must be emailed by selecting the Submit by Email button located at the top of this form or printed by selecting Print Form button, scanned and emailed to email@example.com . Counsel may insert an electronic signature or use s/ attorney222s name for submitting the form by email. If the form cannot be emailed, the printed form can be signed and mailed to the Clerk in hard copy. I. TO BE COMPLETED BY ALL APPLICANTS Full Name: State Court Bar Membership(s) and Bar Number(s): Federal Court Bar Membership(s) and Bar Number(s) (if applicable): American LegalNet, Inc. www.FormsWorkFlow.com 2 Last 4 Digits of Social Security #: E-Mail address: Firm Name: Office Address: Office Phone Number: Please check if your personal information (i.e. name, address, e-mail address, phone number has been changed. Date of Admission to Third Circuit Court of Appeals: Please check if you may have been admitted under a different name and list the original name or possible names for admission: All of the information I have provided in this form is true and correct to the best of my knowledge, information, and belief. Signature: Date: II.REQUEST TO RENEW ACTIVE STATUS To be completed by attorneys who have not appeared in a case within the past five years and wish to continue to remain in active status in the rolls of the Court. Place an X beside this selection. I request to renew active status. I acknowledge that it is my responsibility to advise the Clerk if my contact information changes. I understand that this renewal is valid for a period of five years from the date of this form unless I enter an appearance within that time. See R.A.D.E. 17.2 . American LegalNet, Inc. www.FormsWorkFlow.com 3 Signature: III.REQUEST TO RETURN TO ACTIVE STATUS To be completed by attorneys who have been marked inactive or retired but wish to resume active status in the Court of Appeals. Place an X beside this selection and sign the following statement under penalty of perjury. I request to adjust my status from: inactive to active status retired to active status. I, , hereby state under penalty of perjury that, to the best of my knowledge, I am not currently subject to any criminal conviction or disciplinary sanction by any state or federal bar of which I am a member. Signature: IV.REQUEST TO ADJUST FROM ACTIVE TO ANOTHER STATUS To be completed by attorneys who wish to be marked inactive or retired in the rolls of the Court. Place an X beside the appropriate selection. I request the Clerk to adjust my status to inactive. I request the Clerk to adjust my status to retired. I acknowledge that any future request to return to active status is governed by R.A.D.E. 17.6 and 17.7 . Signature: V. OTHER To be completed by any individuals directed by the Clerk222s Office to file this form but who believe they were contacted in error; i.e., because they appeared in a case within the past five years (R.A.D.E. 17.2) or for any other reason. If you have entered an appearance in a case please include the case number. Note that R.A.D.E. 17.2 provides, American LegalNet, Inc. www.FormsWorkFlow.com 4 223For ease of administration, the 5 year period runs from the last date of an entry of appearance, not from the date a case was closed.224 Explain: Signature: 04/02/2018 American LegalNet, Inc. www.FormsWorkFlow.com