Fill out form completely. Do not leave any blank spaces.  If the question does not apply, type in N/A.

Name:

Address:

Telephone Number:

Case Number:

Court in which conviction occurred:

Conviction Date:
(Contact the court to find out the exact conviction date)

Criminal Offense for which you were convicted:

Indicate whether you were imprisoned as a result of your criminal conviction:

Select OneYesNo

If yes, indicate the date you were discharged:

Indicate whether you have ever filed an application to set aside a criminal conviction:

Select OneYesNo

If yes, indicate whether it was for this or another conviction:

Select OneThis convictionAnother conviction

Indicate what happened with that application:

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