Re-Entry Assistance Request Form

Please answer every question the best you can.
Applicant Information
Last Name
First Name
Middle Name
Home / Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Security Number
Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
E-mail Address
example@example.com
Driver's License / State ID (State & Number)
Case Number(s) — Leave blank if you don't know or are not sure
Preferred Contact Method
May We Leave a Voicemail?
Alternate Contact - Name

First NameMiddle NameLast Name
Alternate Contact - Relationship to You
Alternate Contact - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
What You Are Asking Us to Help With
Please check one or more:

Other
If Other, Describe
Do You Have Pending Case(s)?
If Yes, Who Is Your Attorney?
Represented by an Attorney with the Public Defender's Office in the Past?
If Yes, When Was the Last Time?
Attorney's Name (Past Representation)
Certification
I certify that the information I have given on this form is true and complete to the best of my knowledge.
Certification - Print Name

First NameMiddle NameLast Name
Certification - Signature
Certification - Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorization A — Driver's license information
I give the Shelby County Public Defender, and anyone working on my case, permission to get my driver’s license record and the written requirements for getting my license back. They may get this from the Tennessee Department of Safety and from any other agency that has it. This permission ends one year from the date I sign below.
Authorization A - Print Name

First NameMiddle NameLast Name
Authorization A - Signature
Authorization A - Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Authorization B — Limited representation by a volunteer lawyer
Sometimes the Shelby County Public Defender collaborates with volunteer lawyers in private practice to help people who need re-entry assistance. By signing below, you give the Shelby County Public Defender permission to let a volunteer lawyer who does not workfor the office handle this matter for you. You also give permission to share your information with that volunteer lawyer as needed. If a volunteer lawyer takes your case, they will only help with the request you checked on this form. You agree that they are not your lawyer for anything else. You also agree that they will not represent you if you appeal a decision that goes against you.
Authorization B - Print Name

First NameMiddle NameLast Name
Authorization B - Signature
Authorization B - Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Certificate of Employability
Many jobs and licenses are closed to people with certain convictions. A certificate of employability is an order signed by a judge that removes that automatic block for many of them. It does not erase, seal, or expunge your conviction, and it does not guarantee that you will be hired or licensed — an employer or licensing board can still look at your record. What it does is keep your conviction from disqualifying you automatically in many situations, and it gives employers protection if they hire you. This is a longer process than the other requests on this form. It means filing a petition with the court, giving notice to the district attorney, and waiting for a judge to decide. The court may also set a hearing. Expect this to take several months, and sometimes longer. There are also waiting periods after you finish your sentence before you can file.
Only answer the questions below if you are asking for a certificate of employability.
Certificate of Employability - Case Number
Certificate of Employability - Case Number 2
Certificate of Employability - Case Number 3
Certificate of Employability - Court / County
Certificate of Employability - Court / County 2
Certificate of Employability - Court / County 3
Certificate of Employability - Offense
Certificate of Employability - Offense 2
Certificate of Employability - Offense 3
Certificate of Employability - Date of Conviction

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Certificate of Employability - Date of Conviction 2

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Certificate of Employability - Date of Conviction 3

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date You Finished Your Sentence

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are You Currently on Probation or Parole?

Other
Current or Most Recent Employer
Position
Employment Dates
Job, License or Certification You Are Seeking
Education, Training or Programs Completed Since Release
Reference 1 - Name

First NameMiddle NameLast Name
Reference 1 - Relationship to You
Reference 1 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 - Name

First NameMiddle NameLast Name
Reference 2 - Relationship to You
Reference 2 - Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

Please answer every question the best you can.

Applicant Information

What You Are Asking Us to Help With

Certification

I certify that the information I have given on this form is true and complete to the best of my knowledge.

Authorization A — Driver's license information

Authorization B — Limited representation by a volunteer lawyer

Certificate of Employability

Only answer the questions below if you are asking for a certificate of employability.