NOBLE COUNTY COMMUNITY CORRECTIONS APPLICATION

NOBLE COUNTY COMMUNITY CORRECTIONS APPLICATION
NOBLE COUNTY COMMUNITY CORRECTIONS APPLICATION AND SCREENING REQUIREMENTS:
- Fill out this application completely
- Applications will be processed and screened in the order they are received.
- If additional information is needed to process the application, CC staff will attempt to contact applicants TWICE. If the applicant does not respond within seven days, a denial will be filed with the Court.
- The phone of CC appears as a private or blocked number. CC will leave a voicemail if no answer, and it is the responsibility of the applicant to return the call.
- An acceptance or a denial will be filed with the Court stating the decision of the screening committee.
- To complete your application on line go to https://form.jotform.com/203136039257149 and submit the fillable form.
Full Name*

First NameMiddle NameLast Name
Other Last Names Used*
Maiden, married, etc. If none, enter N/A
Date of Birth*

MonthDayYear
Date
Place of Birth*
City, State, Country
Social Security Number*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
County of Residence*
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you lived at this address*
If placed on Home Detention will you reside at a different address? If yes, please list that address here:
Name of Sentencing Court*
Cause Number(s) of the cases you want to serve on Community Corrections. Your Application will not be processed without correct cause number information*
Prosecuting Attorney*
Defense Attorney*
Current Offense(s)*
Victim(s) If applicable
Sentence Received (if known)
Next Court Date*

MonthDayYear
Date
Report By Date, if applicable

MonthDayYear
Date
Enter any other pending cases you have below:
Pending case Offense blanks County where pending blank
List your criminal history*
Offense/Year/County or State where committed. If no criminal history please enter N/A
Do you have prior or pending Federal Charges?
Enter Yes or No
Details
If none, enter N/A
Do you have a history of violence?
Enter Yes or No
Details
If no, enter N/A
Have you had criminal charges filed against you in any other state?
Enter Yes or No
Details
Where, charges, when , etc.
Have you had a protective order?
Enter Yes or No
Details
With who, year issued/removed?
Have you been in WR before?
Enter Yes or No
Details
Offense, County, year completed, successful or not?
Have you been in Home Detention before?
Enter Yes or No
Details
Offense, County, year completed, successful or not?
Have you had violations or write ups while incarcerated or on Home Detention or Work Release in the past?
Enter Yes or No
Details
Current employer*
Current Job Title/Description*
Weekly Gross Pay*
Is your employer aware you are on community corrections?
Enter Yes or No
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor Name*
Work Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of Hire*

MonthDayYear
Date
Normal Work Schedule*
Other Income*
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List the Name, Date of Birth, and phone # for all people who would live with you if you are placed on Home Detention*
Marital Status*
Number of Dependents *
Name, Age and relationship of all dependents
Vehicle Type
License Plate #
Auto Insurance Agent
Auto Insurance Policy #
If you do not drive, who will provide you transportation while on Community Corrections
Full Name
What type of vehicle do they drive?
What is their license plate #?
List your prior employers over the past five years. Include your length of employment and reason for leaving*
If unable to pay the supervision fees, do you have someone to assist in payment?
List their Name and Telephone number
Highest grade of school completed*
Name of last school attended*
Have you ever been on probation before
Answer Yes or No
Have you ever been on Community Corrections before?
Answer Yes or No
Have you ever been convicted of a sex offense?
Answer Yes or No
Are you currently a student?
Answer Yes or No
Are you a U.S. citizen?
Answer Yes or No
Were you ever in the military? If so, what branch?*
Date you started with the military

MonthDayYear
Date
Date you were discharged

MonthDayYear
Date
Do you consume alcohol?
Answer Yes or No
If yes, how much per week?
Date of last use of alcohol

MonthDayYear
Date
Do you consume drugs?
Answer Yes or No
If yes, which drugs?
Date of last use of drugs

MonthDayYear
Date
Are you currently in substance abuse or mental health treatment?*
If yes, list type of services at which agency
Were you previously in substance abuse or mental health treatment?*
If yes, list type of services at which agency
Are you receiving any medical treatment at this time?*
Are you taking any medication at this time?*
Please list the medications you are taking at this time:
Signature*
Date*

MonthDayYear
Date
Should be Empty: