Rule 8.105 Application

Pursuant to Rule 8.105

Personal Information

Name

John Smith

SSN

***-**-****

Mailing Address

3855 Lake Clearwater Place

City

Sarasota

State

Florida

Zip/Postal Code

90210

Home Phone

(812) 111-5100

Cell Phone

(812) 111-5101

Office Phone

(812) 111-5102

Other Phone

(812) 121-5203

E-Mail Address

sample@email.com

Law School

List the law school from which you graduated and the date your J.D. degree was awarded:

Law School

Date J.D. degree awarded (month/year)

Jurisdiction

List every U.S. jurisdiction (state, territory, or District of Columbia) where you currently hold an active license to practice law.

Jurisdiction

Date Admitted

Employer

List the employer for which you will be serving as in-house counsel in Missouri:

Name of Corporation, Association, Business, or Entity:

Street Address:

City:

State:

Zip Code:

Telephone:

Briefly describe the nature of business conducted by employer:

Authorization

All applications are confidential and we cannot discuss the status of your application without your authorization, including a secretary, administrative assistant, or spouse who contacts us on your behalf. Do you want to designate someone with whom you authorize us to discuss your application?

Provide the name and telephone number of the person and describe the relationship (e.g., assistant, spouse, friend, etc.):

Name of Person:

Telephone:

Email Address

Relationship:

Attestation

I understand this Application for Limited Admission for In-House Counsel is a continuing application and must state correctly and completely the information requested during the time this application is pending before the Board of Law Examiners. I incorporate into this application all statements made in the Application for Character and Fitness Report submitted concurrently herewith. No later than thirty (30) days after the happening of an event, I will file an update to this application to notify the Board of Law Examiners as to any change in respect to any information provided or sought in this application, or to any incident which may have any bearing upon any information sought. I affirm under penalty of perjury that all statements in this application are true and complete.

Agree