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2. Date*
   Date
3. Case No. *
5. Name*
6. Email Address
8. Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
18. With whom do you live with?*
20. Are you employed?*

    1. Yes
    2. No
21. If "yes", list employer(s)*
23. Hours per week*
24. List Hourly Rate / Salary*
26. Do you posses a valid driver's license? *

    1. Yes
    2. No
27. If "yes" is license:*

    1. Restricted
    2. Full privileges
29. Are you attending treatment program(s)?*

    1. Yes
    2. No
30. If "yes", where? (list all that apply):*
32. Name of counselor(s):*
34. Have you paid all your Fines, Costs and Probation Oversight fees?*

    1. Yes
    2. No
35. If no check with District Court Records Department on First Floor for balance and due date.
37. Since your last report have you had ANY contact with Police?*

    1. Yes
    2. No
38. Check all that apply*

    1. Ticketed
    2. Arrested
    3. Other
39. Provide explanation *
41. Do you have any special problems, concerns or comments?*

    1. Yes
    2. No
42. Please list your concerns here*
44. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date. I have reviewed this document and the statements it contains are true to the best of my knowledge, information, and belief.

    1. I agree.
46. Electronic Signature*
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48. 1. Receive an email copy of this form.
49. Email address

    This field is not part of the form submission.

50. Submit Submit and Print

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