APPLICATION FOR PRE-TRIAL DIVERSION PROGRAM

1.	Name__________________________________________  Telephone__________________________

2.	Address____________________________________________________________________________
                                  (Street)                                                       (City)                                               (State)                                        (Zip)

3.	Age____________	4.   Date of Birth____________ 	5.  Place of Birth_____________________

6.	Sex____________	7.   Race___________________	8.  Social Security No_________________

9.	Marital Status_______________	10.  Spouse’s Name_____________________________________

11.	Number of Dependents_________	Names/Ages___________________________________________

12.	Education (List school name, location and grade or degree completed.)
__________________________________________________________________________________
__________________________________________________________________________________

      13.  Vocational Training ___Yes	___No		Type__________________________________________

      14.  Military Service ___Yes	___No		Branch_________________________________________
	Type of Discharge____________________	Date of Discharge________________________________

      15.  Nearest Contact Name________________	Address________________________________________
	 Relationship to Defendant_____________

      16.  Defense Attorney Name_______________	Address________________________________________
	 Phone Number______________________

      17.  Present Employer____________________	Phone Number___________________________________
             Address____________________________	Date Employed___________________________________
	Occupation__________________________	Salary _________________________ per week/month

18.	Employment History (Begin with last previous employer.)
Name______________________________	Phone Number__________________________________
            Address____________________________	Date Employed__________________________________
	Occupation__________________________	Reason for Leaving_______________________________
	(List additional previous employers and information on back)

19.	Present Sources of Income:  Dependent’s Employment________________________________________
Spouse’s Employment_______________________	Unemployment Compensation_________________
Public Assistance___________________________	Parents_____________Relatives_______________
Friends_____________________  Other________________    Total Income______________________

      20.  Prior Offenses Record ___None	___Juvenile	___Adult
Criminal History (Begin with first arrest and include traffic violations only if they involved liquor and/or drugs, i.e. DUI, transporting open container, etc)____________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

21. Personal References (List name, address, telephone and relationship)
___________________________________________________________________________________
___________________________________________________________________________________