Anti-Corruption Program Application Form

Application Form

Please fill in the form below.
Applicant Information
Full Name*

PrefixFirst NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail*
Do you wish to keep your identity confidential

YESNO
NOTE: Upon request of an applicant at the time the application is made, DCJ and any other governmental agency involved in the criminal proceeding shall not disclose the identity of the applicant, subject to any statute, rule of Court or judicial decision to the contrary which may require divulgence of such identity to certain parties including, in certain circumstances, a criminal defendant.
Applicant's Attorney Information (If available)
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
E-mail
Information Provided

All information, reports, applications or other documentation received or maintained by DCJ pursuant to the ACWP are confidential criminal investigatory records pursuant to the Open Public Records Act, N.J.S.A. 47:1A-1, et seq., and shall not be subject to public access.

Any statements by the applicant on the Application Form may not be used in a direct case against the applicant in any New Jersey state criminal proceeding, except if the applicant provides false or misleading information or is ever a witness against the State at any trial or other judicial proceeding. The State may make derivative use of and may pursue any investigative leads against the applicant or others. Should acceptance be revoked for any reason, any statements made or information provided by the applicant may be used without limitation.
Incident Information
Date of Incident

MonthDayYear
Location
Detailed Description of Incident/Crime:
Suspect's Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Witness Information
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you wish to be considered for a waiver from criminal prosecution under the ACWP?

YESNO
Acknowledgment

Please read and sign below
I hereby certify that the information provided above is true and accurate. I am aware that if any of the foregoing information is willfully false I am subject to punishment.

I hereby certify and acknowledge that submission of this Application Form cannot be construed as any waiver of prosecution.

I hereby certify and acknowledge that a decision of the DCJ Director or a designee regarding eligibility for entry into the program shall be final and shall not be subject to judicial review.
Signature:*

By clicking this button it serves as my signature
Date

MonthDayYear
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Application Form

Acknowledgment