Request for Record Restriction

Request for Record Restriction

O.C.G.A. 35-3-37(d) This is Form is only available for offenses in Bibb, Crawford and Peach Counties Failure to complete the process as instructed may hinder the completion of your request for record restriction. Prior to filling out the applicant’s portion of the application, please obtain all documentation of the final disposition of the arrest that is the subject of this restriction. 1. Complete (1) the application form with your case and contact information below and (2) the consent form to authorize our office to run your criminal history. 2. Submit the application, consent form and a copy of the front and back of your ID (driver’s license, state issued identification) with the application. 3. Applications will be completed in the order in which they are received by our office. All applications are date and time stamped upon completion. 4. You will receive an email confirming that your application is complete. You may be invited to attend a Record Restriction Summit or other Record Restriction events. By Completing this form, I hereby give my consent for the Office of the District Attorney of the Macon Judicial Circuit and/or Georgia Justice Project to receive any Georgia criminal history record information pertaining to me, as authorized under state and federal law for individuals with a criminal justice agency. I am requesting that the Office of the District Attorney of the Macon Judicial Circuit and review my application for eligibility to restrict a prior conviction.
APPLICANT INFORMATION
To be completed by Applicant
Full Name*

First NameMiddle NameLast Name
Date of Birth*
Date of Birth*

MonthDayYear
Date
Race*
25 character limit
Sex*
Sex*
SSN*
Phone Number*

Area CodePhone Number
Phone Number*
Email*
50 character limit
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Street Address*
40 character limit
Street Address 2
10 character limit
City*
30 character limit
State / Province*
ZIP*
Arresting Agency*
Arresting Agency

Bibb CountyPeach CountyCrawford CountyOther
If your arresting agency does not appear but you were arrested in Bibb, Crawford, or Peach Counties, then please contact 478-621-6427.
Arresting Agency*
Campus Police
Date of Arrest*
Date of Arrest*

MonthDayYear
Each Submission is for only one arrest.
Offense(s) Arrest For:*

0/50
I request the arrest record information (Date of Arrest and Associated Charges) described above pertaining to me be restricted from the records of the arresting agency pursuant to the provisions of O.C.G.A 35-3-37(d)

By typing your name below, I, the above named applicant give my consent for my Criminal History to be ran by the arresting agency or prosecutor’s office in the event it becomes necessary for the purpose locating the correct record for which I am asking be restricted.
Signature*

Clear
Signature*
Date*

MonthDayYear
Date
By checking this box I confirm I am not a robot.*

Agree
Should be Empty: