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):

Month

Day

Year
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:

Month

Day

Year
Charge(s) at time of arrest/citation:
Charge(s) at time of trial:
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.
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