SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN MATEO THE PEOPLE OF THE STATE OF CALIFORNIA Plaintiff, vs. Defendant APPLICATION FOR ADMISSION INTO VETERANS TREATMENT COURT 1. I, ____________________________, am an Active Duty Member, or a Veteran with an Honorable or General Discharge, of the United States Armed Services. I understand that: a. To be considered for this program, signed copies of this Application and the Consent to Release of Confidential Information forms must be delivered to: i. Service Connect Office, County of San Mateo Hall of Justice and Records, 1 st Floor, 400 County Center, Attn: Veterans Court Clinician Daniel Gunther (Fax 650-701-0277); and, ii. Adult Probation, County of San Mateo, Hall of Justice and Records, 400 County Center, 5th Floor, Redwood City, CA, Attn: Michael Leon (Fax 650-363-4829). b. c. d. 3. Veterans Treatment Court involves a long-term treatment program and probation terms. If admitted, I will be subject to Veterans Treatment Court rules, which may include electronic monitoring, drug testing, and, for any rules violations, flash incarcerations. Any restitution that I owe to any victim of a crime I have committed will remain due and payable until paid, even if I complete Veterans Treatment Court. Case Number(s): 2. My full name, address and phone number are: _____________________________________________________________________________________ _____________________________________________________________________________________ I am represented by: (name, address & telephone number of your attorney, if you have one) _____________________________________________________________________________________ _____________________________________________________________________________________ I have been convicted of the following charges (or have admitted the following Probation Violations) in San Mateo County Superior Court Case Number indicated above: _____________________________________________________________________________________ _____________________________________________________________________________________ I am asking to be admitted into Veterans Treatment Court because: (if more space needed, attach additional page): ____________________________________________________________________________________ ____________________________________________________________________________________ 4. 5. 6. I, ____________________________, understand all of the above, and acknowledge that everything I have said about myself in the preceding answers is true. Dated: Form adopted for Mandatory Use APPLICATION Local Court Form VTC 01 [Rev. May 2012] ________________________________________ Veteran's Signature FOR ADMISSION INTO VETERANS TREATMENT COURT Additional page attached Pen.Code § 1170.9 American LegalNet, Inc. www.FormsWorkFlow.com