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FFICE OF

DMINISTRATIVE

EARINGS

Oregon

PO Box 14020

Salem, OR 97309

Kate Brown, Governor

(503) 947-1918

FAX (503) 947-1920

In re: ______________________________)

Certificate of Compliance

)

For Pro Hac Vice Admission

Name of Out-of-State Attorney

(print), am an attorney in the State of _______________, and I

intend to seek pro hac vice admission in accordance with ORS 9.241, OAR 137-003-0550 and UTCR 3.170 in the following

Office of Administrative Hearings proceeding:

Case Name: ______________________________________________________________________

Case No.: _________________________

Agency Name _______________________________

I certify that (check all that apply):

I am an attorney in good standing in the State of ___________________________, as evidenced by the attached good

standing certificate issued by the licensing authority in that state.

I am not subject to any pending disciplinary proceedings in any jurisdiction; or

I am subject to pending disciplinary proceedings in another jurisdiction, the nature and status of which are

described in an attachment to this certificate.

I intend to associate in the above-referenced proceeding with ____________________________, OSB No. _______, an

active member in good standing of the Oregon State Bar, who will participate meaningfully in the matter.

I will comply with applicable statutes, laws, and procedural rules of the State of Oregon; be familiar with and comply with

disciplinary rules of the Oregon State Bar; and submit to the jurisdiction of the Oregon courts and Oregon State Bar with

respect to acts and omissions occurring during my pro hac vice admission.

My private law practice activities in Oregon are covered by professional liability insurance substantially equivalent to the

Oregon State Bar Professional Liability Fund plan, as evidenced by the attached certificate of insurance coverage.

I agree, as a continuing obligation of pro hac vice admission, to promptly notify the Agency and the Office of

Administrative Hearings of any changes in my insurance coverage, or my admission or disciplinary status in any other

jurisdiction.

I will provide to the Oregon State Bar a copy of the order admitting me pro hac vice in this matter when such an order is

granted. In the event pro hac vice admission is revoked, I will promptly notify the Oregon State Bar.

I acknowledge this application is for a period of twelve months from the date of the approval and new application must be

submitted to continue my pro hac vice admission in the matter for every twelve-month period thereafter.

Dated this

day of

, 20

Bar No

(Applicant Signature)

(Home Jurisdiction)

Mailing Address:

Phone:

FAX:

Email:

APPLICATION APPROVAL STATUS:

APPROVED

NOT APPROVED

Dated this

day of

, 20

Signature

Printed Name

Printed Title

H:\Website\Pro_Hac_Vice_Atty32015.doc

March 10, 2015

Certificate Of Compliance For Pro Hac Vice Admission - Oregon Administrative Hearings

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