Name * Attorney Bar ID # * Reason for Requested Change * -Select-ActiveInactiveRetiredDeceased Date Effective * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023 Office Name if Applicable Mailing Address * This address is public record and will appear on the docket sheet of any cases the attorney has appeared in. Please consider this when using home address and telephone number. City * State * Zip * Phone Number * Email Address * Attorney Signature: s/ Date Month MonthNov Day Day30 Year Year2023 Representative Signature: s/ Relationship to Attorney Date Month MonthNov Day Day30 Year Year2023
