Applicants Personal Questionnaire (Drug Court Option) {CRM-226}

P. O. Box 23596 San Diego, California 92193-3596 SAN DIEGO COUNTY PROBATION DEPARTMENT ADULT SERVICES APPLICANTS PERSONAL QUESTIONNAIRE (Drug Court Option) You have been ordered to complete Drug Court as a condition of Formal Probation. You are to follow the rules set forth by the Drug Court and must abide by all conditions of Probation. Please complete and return this questionnaire to the courtroom clerk by your next Drug Court Appearance Date. If you have any questions, please speak with your Attorney or Drug Court Case Manager. Date: ____________________ Name: _______________________________________________________________________________________________ Birthdate (day/month/year) __________/___________/__________Social Security # ________-_______- ________ Address: ______________________________________________________________ Tel # (______) ________-___________ Number Street City Zip Code Education ________________________________________________________________________________________________________ Grade Completed School Name Vocational Training ___________________________________________________________________________________________________ Skill School Name Driver's License # __________________Auto Model/Make ______________________________ License # ________________ LIST ALL PRIOR ARRESTS, WHETHER CONVICTED OR NOT: Offense Arresting Agency Date Disposition ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ HAVE YOU EVER BEEN REFERRED TO ADULT OR JUVENILE PROBATION OR PAROLE? Agency Location Date ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ HAVE YOU EVER BEEN IN A JAIL, PRISON OR MENTAL HOSPITAL FOR JUVENILES OR ADULTS? Name of Institution Date Why were you there? ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ GIVE COMPLETE NAMES AND MAILING ADDRESSES FOR THE NEXT THREE QUESTIONS: Marital History: Date Separated/ Current Married to: Date Divorced Address Tel # Employer Tel# ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Parents: Name Address Tel # Birthdate Where Employed Father:__________________________________________________________________________________________________ Mother: (Maiden Name) ___________________________________________________________________________________ Stepfather: ______________________________________________________________________________________________ Stepmother: _____________________________________________________________________________________________ Brothers/Sisters: __________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ SDSC CRM-226(New 1-06) Page 1 American LegalNet, Inc. www.USCourtForms.com Probation Questionnaire (continued) Children/Stepchildren: Names Address Tel # Birthdates Where Employed ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ EMPLOYMENT HISTORY (List present or last employment first) From Month To Month/Year Salary Employer Name, Business, Present Address Telephone # Position LIST PERSONAL REFERENCES WITH COMPLETE MAILING ADDRESSES (Persons who know you, other than relatives): Name Address Tel # ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ I CERTIFY THAT ALL OF MY STATEMENTS AND ANSWERS IN THIS QUESTIONNAIRE ARE COMPLETE AND TRUE. I UNDERSTAND THAT ANY WILLFULLY FALSE STATEMENT I MADE WILL AFFECT MY PARTICIPATION IN THE DRUG COURT PROGRAM. ________________________________________________________________________________________________________ Date Signature If someone helped you to complete this questionnaire, please print his/her name below: Name: _________________________________________________________________________ SDSC CRM-226(New 1-06) Page 2 American LegalNet, Inc. www.USCourtForms.com