Pretrial Diversion Program Form

Pretrial Diversion Program Form

 

Date: _______________________________

 

Name: _________________________________________________________________

 

Address:________________________________________________________________

 

City: _____________________________________ State: ________ Zip:____________

 

Phone Number: _______________________________

 

Email Address: ________________________________

 

Date of Birth: ___________________ Social Security Number: ___________________

 

Charge: _____________________________ Cause Number: _____________________

 

Have you ever been convicted of a crime? Yes No

 

If yes, explain:__________________________________________________________

______________________________________________________________________

 

Have you ever been charged or arrested for a crime? Yes No

 

If yes, explain:__________________________________________________________

______________________________________________________________________

 

Have you ever participated in a Pretrial Diversion Program before this incident? Yes No

 

If yes, explain when and where:____________________________________________

______________________________________________________________________

 

Are you represented by legal counsel? Yes No

 

If yes, whom? __________________________________________________________

 

Next court date: ________________________________________________________