Attachment C

Record of Criminal Cases/Traffic Violations

Name

First Middle Initial Last
Email*
Please indicate whether the matter described below involves a criminal matter, or a minor traffic violation not involving drugs/or alcohol.
- Criminal Matter
- Moving Traffic Violation
Date of Incident ( or time period involved):

MM

DD

YYYY
Age at time of incident:
Location of Incident:
City / County State / Province / Region
Title of complaint or indictment:
Court File Number
Date(s) the complaint or indictment was filed:
Name and complete address of court or entity with possession of documents:
Name of Court Address City, State, ZIP Code Telephone Number
Name and complete address of law enforcement agency involved:
Name Address City, State, ZIP Code Telephone Number
Name and complete address of entity bringing charges:
Name Address City, State, ZIP Code Telephone Number
Name and complete address of attorney retained in defense of this matter:
Name of Attorney Address City, State, ZIP Code Telephone Number
Date first heard:

MM

DD

YYYY
Charge(s) at time of arrest/citation:
Charge(s) at time of trial:
Date Format: MM slash DD slash YYYY
Final Disposition:
Brief description of incident as well as circumstances leading up to and surrounding the same:
***Attach, where applicable, certified copies of docket sheet(s), the charging documents, police records, etc., as well as the judgment of convictions, the presentence investigation (if applicable) and any other relevant pleadings.
Drop files here or