900-00027 - Vermont Pro Bono Emeritus Registration (10/2017) Page 1 of 1
Vermont Pro Bono Emeritus Licensing Statement
INSTRUCTIONS: To obtain a Pro Bono Emeritus limited license to practice law, send this completed form, the
completed Attorney Licensing Statement, a check for $75 made payable to Attorney Licensing, and, unless you are
admitted in Vermont, an original Certificate of Good Standing from a licensing state or the District of Columbia, to:
Office of Attorney Licensing
Costello Courthouse
32 Cherry Street, Suite 213
Burlington, VT 05401
Please allow two weeks for processing. Questions should be directed to JUD.AttyLicensing@vermont.gov.
Applicant Name:
If known: Name of Associated Nonprofit Organization:
Name of Supervisor/Contact Person:
Office Address:
City: State: Zip:
Phone: Fax: Email:
By signing and submitting this form, I understand that I am certifying each of the following:
• I am admitted and in good standing in a licensing state or the District of Columbia.
• I am not suspended or disbarred in any jurisdiction in which I am admitted or was formerly admitted.
• I am subject to the Mandatory Rules for Continuing Legal Education, except that I need only complete at least 8 hours
of accredited continuing legal education, including at least 2 hours in ethics, during each 2-year licensing period.
• I am subject to the disciplinary jurisdiction of the Vermont Supreme Court and the Professional Responsibility
Board, as well as to the Vermont Rules of Professional Conduct.
• I will not practice law in Vermont except to provide legal services without fee or expectation of fee, under the
auspices of a nonprofit organization, to persons of limited means or to charitable, religious, civic, community,
governmental, and educational organizations which are designed primarily to address the needs of persons of
limited means.
• I will be covered by the malpractice insurance carried by the organization under whose auspices I am practicing
law.
Date: _____________ Applicant’s Signature:
Subscribed and sworn to before me:
Date: _____________ Notary Public Signature:
Notary Public Printed Name:
My Commission Expires on:
