STATE OF ILLINOIS CIRCUIT COURT OF LAKE COUNTY APPLICATION FOR CERTIFICATE OF RELIEF FROM DISABILITIES Case Number: Applicant's Name: Address: street city state zip Social Security #: Offense of Conviction: Date of Birth: Date of Sentence: Pursuant to the provisions of 730 ILCS 5/5-5.5-15, application is hereby made for issuance of a CERTIFICATE OF RELIEF FROM DISABILITIES to relieve the holder of disabilities or bars to employment herein enumerated: The applicant hereby affirms that he/she is an eligible offender as specified by the provisions of 730 ILCS 5/5-5.5-15, and agrees to cooperate with an investigation to determine his/her fitness for a certificate of relief from disabilities. Applicant's Signature: Date: American LegalNet, Inc. www.USCourtForms.com