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2. Case No. *
3. Social Security No.*
4. Age*
5. Date of birth*
   Date of birth
7. Name*
8. AKA (also known as)
   If applicable
10. Address*
12. City*
13. State*
14. Zip Code*
16. Phone Number*
17. Work Number*
    Write N/A if not working
19. Have you lived at this address 3 or more consecutive years? *

    1. Yes
    2. No
20. If no, how often have you moved in the past 3 years?*
24. Father's name
25. Mother's name
26. Stepfather's name
    If applicable
27. Stepmother's name
    If applicable
29. Citizen of the United States?*

    1. Yes
    2. No
30. If no, name country of citizenship*
31. Legally in the United States on a temporary basis?*

    1. Yes
    2. No
32. If yes, enter green card no. *
36. Select one. Are you:*

    1. single
    2. married
    3. separated
    4. divorced
    5. widowed
    6. living with someone (partner)
37. Husband/wife/partner's name*
38. How many times have you been married?
42. List all children (including stepchildren)
44. Child's first and last name
45. Child lives with?
46. Is this a stepchild?
47. Child support amount paid
    If applicable
49. Child's first and last name
50. Child lives with?
51. Is this a stepchild?
52. Child support amount paid
    If applicable
54. Child's first and last name
55. Child lives with?
56. Is this a stepchild?
57. Child support amount paid
    If applicable
59. Child' first and last name
60. Child lives with?
61. Is this a stepchild?
62. Child support amount paid
    If applicable
64. Do you need to list more children?*

    1. Yes
    2. No
65. Add additional child information here:*
69. Education Level*

    1. Partially completed high school
    2. High school graduate / GED
    3. Attended college
70. What school did you attend?*
71. Last year completed or year graduated*
75. Are you currently employed?*

    1. Yes
    2. No
76. Name of employer*
77. Date started*
    Date started
79. Pay per hour*
80. Time of day worked (shift hours)*
82. Were you ever fired from a job?*

    1. Yes
    2. No
83. If yes, why?*
85. Additional source of income?*

    1. Yes
    2. No
86. If yes, what is the source and rate of pay?*
90. Have you ever been in the Armed Services?*

    1. Yes
    2. No
91. Which branch?*

    1. Army
    2. Navy
    3. Air Force
    4. Marines
    5. Other
92. Dates served*
    From what date to what date?
94. Type of discharge*

    1. Honorable
    2. Dishonorable
    3. Other
95. Please explain*
99. Are you currently covered by insurance?*

    1. Yes
    2. No
100. Name of insurance *
101. Are you the policy holder?*

     1. Yes
     2. No
102. Name of policy holder*
     What is relationship to you?
104. Have you been seriously ill or injured during the past five years (include current illness)*

     1. Yes
     2. No
105. If yes, explain*
107. Currently prescribed medications?*

     1. Yes
     2. No
     3. N/A
108. Please list all medications currently being taken*
110. Are you taking the medications prescribed to you?*

     1. Yes
     2. No
111. If no, explain*
115. Ever involved with Juvenile Court?*

     1. Yes
     2. No
116. Any prior adult convictions?*

     1. Yes
     2. No
117. Please describe (include years, offenses and courts)*
119. Any pending charges against you?*

     1. Yes
     2. No
120. Please describe (include years, offenses and courts)*
122. Have you ever been on probation?*

     1. Yes
     2. No
123. Please describe (include years, offenses and courts)*
125. Currently on probation or parole?*

     1. Yes
     2. No
126. Sentencing court*
127. Offense(s)*
128. Probation/Parole Agent/Officer Name:*
132. Do you or have you used alcohol?*

     1. Yes
     2. No
133. Age you first used alcohol*
134. Average amount of alcohol consumed per setting*
135. Date of last alcohol consumption*
     Date of last alcohol consumption
137. Which best describes your pattern of alcohol use:*

     1. Daily
     2. Weekly
     3. Monthly
     4. Bimonthly
     5. Yearly
139. Do you or have you used drugs?

     1. Yes
     2. No
141. Which best describes your pattern of drug use:*

     1. Daily
     2. Weekly
     3. Monthly
     4. Bimonthly
     5. Yearly
142. List all drugs currently using or used*
143. Average amount of drug(s) used per setting*
144. Date of last drug use*
     Date of last drug use
146. Have you partaken in any counseling within the past 5 years? (Include any present counseling)*

     1. Yes
     2. No
147. Provider's name(s)*
148. List types of counseling taken*
150. History of alcoholism or drug addiction in family?*

     1. Yes
     2. No
151. Select all that apply*

     1. Father
     2. Mother
     3. Siblings
152. Do you feel you have an alcohol or drug use problem?*

     1. Yes
     2. No
154. Explain why or why not*
158. DEFENDANTS VERSION: In this area describe your activities that led to your arrest for the offenses in this current case. Include any use of alcohol or drugs and the amounts and time periods in which you used each substance. BE SPECIFIC *
160. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. I have reviewed this document and the statements it contains are true to the best of my knowledge, information, and belief.

     1. I agree.
162. Electronic Signature*
Leave This Blank:


164. 1. Receive an email copy of this form.
165. Email address

     This field is not part of the form submission.

166. Submit Submit and Print

* indicates a required field