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: ________________________________________________________