Uniform PreTrial Diversion Application

INITIAL APPLICATION FOR PRE-TRIAL DIVERSION IN THE CIRCUIT COURT FOR ________________________ COUNTY STATE OF TENNESSEE VS. __________________________________ ) ) ) ) ) DOCKET NO._________________ DATA CONCERNING DEFENDANT NOTE TO DEFENDANT: ALL QUESTIONS MUST BE ANSWERED COMPLETELY, AND IF NECESSARY, ADDITIONAL PAGES MAY BE ATTACHED. 1. Full Name: ______________________________________________________________ Last First Middle Aliases, nicknames, or changes in name: _______________________________________ Birth Date: _____________________________________ Month Day Year Sex: M( ) F( ) 2. 3. 4. 5. 6. 7. Height: ________ Weight: _______ Color of eyes: ________ Color of hair: __________ Social Security Number: __________________ Dr. License Number________________ Address________________________________________________________________ _________________________________________Telephone______________________ 8. Marital Status: Never Married ( ) Married ( ) Divorced ( ) Spouse Deceased ( ) If married, give spouse's name: ______________________________________________ 1 American LegalNet, Inc. www.FormsWorkFlow.com 9. Parents: Father ______________________________ Living ( ) Deceased ( ) Date of Birth: ____________ Place of Birth: ____________________________ Mother _____________________________ Living ( ) Deceased ( ) Date of Birth: ____________ Place of Birth: ____________________________ 10. Children: Yes ( ) No ( ) (INCLUDE CHILDREN BY ADOPTION) Give names and birth dates of each child: _________________________________ __________________________________ __________________________________ If yes, how many ________. __________________________________ __________________________________ __________________________________ How many of these children live with you?_____________________ 11. Are you obligated by Court to pay child support to any of your children. Yes ( ) No ( ) If yes, are you current: Yes ( ) No ( ) 12. Education: (Account for all schools and military academies) Dates Attended From - To ______________ ______________ ______________ ______________ Diploma Received? __________ __________ __________ __________ Name and location of school _______________________________ ________________________________ _________________________________ _________________________________ 13. 14. Intelligence level, (if known): _______________ Has a psychiatric or psychological evaluation ever been performed? Yes ( ) No ( ) 2 American LegalNet, Inc. www.FormsWorkFlow.com 15. If "yes", what diagnosis, if any, was made? ____________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 16. Prior work record of defendant: Name/Address of Employment Reason for Termination Type of Job a. Supervisor Dates Held ________________________________________________________________________ b. ________________________________________________________________________ c. ________________________________________________________________________ d. ________________________________________________________________________ e. ________________________________________________________________________ 1. 2. 3. Did any of employments require a security clearance? Have you ever been refused an employment bond? If the answer to any of the above is "yes", explain: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 17. List any noteworthy physical characteristics or disabilities of the Defendant. ________________________________________________________________________ 18. List all residences since age 18. Dates From - To _____________________ Yes ( ) Yes ( ) No ( ) No ( ) Streets and Numbers City State ________________________________________________ 3 American LegalNet, Inc. www.FormsWorkFlow.com _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ 19. Past and/or present membership in organizations, and community awards: Name and Address __of Organization__ Social, Fraternal, Professional or Other Date From - To Office Held ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 20. Have you ever been detained, held, arrested, indicted or summoned into court as a defendant, or placed on probation, or have you ever been ordered to deposit bail or collateral for the violation of any law? Include all court martials while in military service. Yes ( ) No ( ) 4 American LegalNet, Inc. www.FormsWorkFlow.com If "yes", list date, nature of offense or violation, name and location of the court or place of hearing, and the penalty imposed or other disposition of each case. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ OFFENSE-RELATED DATA 21. 22. Were there any co-defendants in the case? Yes ( ) No ( ) What conviction and sentence, if any, were imposed on co-defendants? ________________________________________________________________________ _______________________________