He Ain't Heavy Pretrial Diversion Program Application
Date of Application
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Month
-
Day
Year
Date
County where offense occurred
Case Number
Date of Arrest
/
Month
/
Day
Year
Date
ADA: Defense Attorney
APPLICANT INFORMATION
Applicant's Full Name
Race
Gender
Male
Female
DOB: SSN: County of Residence
Current Residential Address
Telephone number
Format: (000) 000-0000.
Email Address
example@example.com
Secondary Contact Person (in case Applicant cannot be reached
)
Secondary Contact Person Name
Secondary Contact Person Phone Number
Format: (000) 000-0000.
Relationship to You
Are you currently incarcerated?
Yes
No
If so, where
Are you currently on probation?
Yes
No
If so, for what and where
Current Employer's Name
Current Employer's Name
Current Employer's Address
Current Employer's Telephone Number
Format: (000) 000-0000.
Your Immediate Supervisor's Name
Have you ever participated in any pretrail diversion type program before?
Yes
No
If so, when and for what charge(s)'
Have you previously resolved any charge with First Offender?
Yes
No
If so, when and for what charge(s)?
Have you previously resolved any charge with Conditional Discharge?
Yes
No
If so, when and for what charge(s)?
How many times have you previously been arrested?
How many prior misdemeanor convictions (including nolo pleas) do you have?
How many prior felony convictions do you have?
Do you have any other pending criminal charges?
Yes
No
If so, when and for what charge(s)?
Do you have a High School Diploma or GED?
Yes
No
Do you have the ability to maintain employment and earn income during your participation in the Pretrial Diversion Program?
Yes
No
If any explanation to your response is necessary, you may provide it here
Do you have sufficient transportation to report in person as directed to your Pretrial Diversion Program supervisor?
Yes
No
Signature
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