Pardons Day Registration Form 2024

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Lady Jane has partnered with AYR Wellness, Councilman McClary and the Bloomfield Senior Center, and other community partners to bring to you our Changing Legacies Pardons Clinic.

If you are looking to apply for an absolute pardons to have your Connecticut criminal record erased, please fill out the form below.

The FREE Pardons Clinic will take place on Saturday, March 10 from 10am-3pm at the Bloomfield Senior Center in the Great Room.
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Full Name* This field is required.
First Name
Middle Name
Last Name
3
Preferred Name
4
Date of Birth* This field is required.
Date
Month
Day
Year
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Social Security Number
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Phone Number* This field is required.
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E-mail* This field is required.
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Gender
Male
Female
Other
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RaceSelect All that Apply
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic or Latin
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Age
18-24
25-34
35-44
45-54
55-64
65+
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Marital Status
Single (never married)
Married, or domestic partnership
Widowed
Divorced
Separated
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Current Work Status
Employed full time (40 or more hours per week)
Employed part time (up to 39 hours per week)
Unemployed and currently looking for work
Unemployed and not currently looking for work
Student
Retired
Homemaker
Self-employed
Unable to work
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Do you have one or more convictions in Connecticut?
YESNO
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Do you owe restitution?
YESNO
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If yes, how much do you owe?
$0-$9,999
$10,000-$19,999
$20,000-$29,999
$30,000-$39,999
$40,000-$49,999
$50,000 or more
None
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Do you owe child support?
YESNO
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If yes, how much do you owe?
$0-$9,999
$10,000-$19,999
$20,000-$29,999
$30,000-$39,999
$40,000-$49,999
$50,000 or more
None
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Current Income Level
Less than $20,000
$20,000-$34,000
$35,000-$49,999
$50,000-$74,999
$75,000-$99,999
Over $100,000
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Highest Level of Education
Less than a high school diploma
High school degree or equivalent (e.g. GED)
Some college, no degree
Associate degree (e.g. AA, AS)
Bachelor's degree (e.g. BA,BS)
Master's degree (e.g. MA,MS,MED)
Professional degree (e.g. MD, DDS, DVM)
Doctorate
Certification
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Veteran Status
Currently Serving/Acting Service Member
Retired Non-Active Service Member
Never Served in the Military
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Do you have a Cannabis arrest or conviction?
YESNO
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How many criminal cases do you have?
1
2
3
4
5 or more
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Number of misdemeanors
None
1
2
3
4
5 or more
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Number of felonies
None
1
2
3
4
5 or more
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Please list the charge(s) you intend to have erased:
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What year was your most recent conviction?
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What town(s) were your cases out of?
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Are you currently on probation or parole?
YESNO
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Were you ever on Probation?
YESNO
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Do you have any Connecticut Criminal cases pending?
YESNO
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Do you have any cases in any other state or jurisdiction outside of Connecticut?
YESNO
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Do you have a copy of your State of Connecticut criminal background report?
YESNO
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Are you registered to vote?
YESNO
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Are you available for immediate employment?
YESNO
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Are you interested in a career in the Cannabis industry?
YESNO
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What type of additional services would you like more information about?
Health Insurance
Government Benefits (SSI, Food Stamps)
Housing
Substance Use Treatment
Employment
Childcare
Voter Registration
Starting a Business
Immigration Rights & Services
Mental Health Services
Reentry Information
Finances and Banking
Should be Empty: