Expungement Registration Form/ Cannabis Pardon

Expungement Registration Form/ Cannabis Pardon Request

Fill out the form carefully for registration
Please note this Expungement Clinic is ONLY for conviction cases. Arrest records will not be included in this Clinic.
Name:

First NameMiddle NameLast Name
Last name at conviction(if different):
Other Names Used:
preferred Email Address:
Mobile Number

Area CodePhone Number
Birth Date

MonthDayYear
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Work Number

Area CodePhone Number
Are you Currently Employed

YesNoTemporary assignmentSelf EmploymentOther
Current Monthly Household Income:
Date of Offense:

MonthDayYear
Date
City of Offense
Date of Conviction/plea:

MonthDayYear
Date
Case Number:
Social Security Number:
Charges:
Additional Comments
Is you cannabis conviction for two ounces or less of possession?

YesNo
If your cannabisconviction is for two ounces or less for possession, are you interested in apardon?

YesNo
Were you represented by a lawyer?

YesNoOther
If so Lawyer's Name:
Are you claiming indigency?

yesNoOther
Signature

Clear
Should be Empty:

Expungement Registration Form/ Cannabis Pardon Request