Attachment C

Name*

First NameLast Name
Email*
Exam*

FebruaryJulyN/A - Limited Practice Application
Exam/Application Year:*
Please indicate whether the matter described below involves a criminal matter, or a minor traffic violation not involving drugs/or alcohol.

Criminal MatterMoving Traffic Violation
Date of Incident

MonthDayYear
Date
Age at time of incident:
Location of Incident:
City/County/State (Province or Region)
Title of complaint or indictment:
Court File Number
Date(s) the complaint or indictment was filed:
Name, complete address and phone number of court or entity with possession of documents:
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Name, complete address and phone number of law enforcement agency involved:
Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Name, complete address and phone number of entity bringing charges:
Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Name, complete address and phone number of attorney retained in defense of this matter:
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date first heard:

MonthDayYear
Date
Charge(s) at time of arrest/citation:
Charge(s) at time trial:
Final Disposition:
Brief description of incident as well as circumstances leading up to and surrounding the same:
***Attach, where applicable, certified copies of docket sheet(s), the charging documents, police records, etc., as well as the judgment of convictions, the presentence investigation (if applicable) and any other relevant pleadings.

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