Name of Administrative Law Judge (if known) OAH Docket Number(s)/Case Number(s) Are you representing an individual or business? Individual Business Name of Individual First Name Last Name Name of Business Representative Name First Name Last Name Firm Name Bar number Licensing State Primary Phone Number Phone Number Mobile Phone Number (if different from Primary) Phone Number Email Mailing Address Street Address City/Town State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Postal Code Are there any special conditions of your representation? (such as limited representation, review of file only, etc.) Have you served your notice of appearance on the other parties in the case(s)? Yes No How did you serve the other parties? By submitting this Attorney’s Notice of Appearance, I certify the foregoing information is correct and that I am duly authorized to represent the party named above. Submit Leave this field blank
