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An applicant's written request for acceptance of a Notice of Intent filed late for good cause pursuant to Rule 19-206 and Rule 19-210, shall include a statement indicating:

(a) whether the applicant's failure to timely file was due to facts and circumstances beyond the applicant's control, and stating those facts and circumstances;

(b) whether the applicant presently has a bar application pending in any other state;

(c) whether the applicant presently is a member of the Bar of any other state; and

(d) the specific nature of the hardship that would result if the applicant's request is denied.