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.