ALTERNATIVE INCARCERATION UNIT: HOUSE ARREST NAME: Last____________________________ First _________________________ Middle_____________ Date of Birth____________________________ Age_________ Race_______________ Sex__________________ Height__________ Weight___________ Eyes____________ Hair____________ Social Security #____________________________ Place of Birth_______________________________________ Home Address________________________________________________________________________________ City_____________________________ State____________________________ Zip Code___________________ Home Phone #________________________________ Cell Phone #_____________________________________ DRIVERS LICENSE: State__________________________________ Number____________________________ Make and Model of your vehicle__________________________________________________________________ License Plate #____________________________________ State licensed in______________________________ List any other vehicle that you may have access to____________________________________________________ LIST ANY AND ALL ALIAS OR A.K.A. YOU HAVE EVER USED: ___________________________________ _____________________________________________________________________________________________ LIST ALL SCARS, MARKS AND TATTOOS: ______________________________________________________ _____________________________________________________________________________________________ EMPLOYMENT HISTORY: Current or Past Employer_______________________________________________ Address_______________________________________________________________________________________ City_____________________________________ State_____________________ Zip________________________ Occupation / Title_______________________________________________________________________________ Date of Hire________________________________ Hourly / Monthly / Wage______________________________ Supervisor__________________________________ Work Phone _______________________________________ How will you get to and from work________________________________________________________________ CRIMINAL HISTORY: Are you currently named in a restraining order of any kind? YES________ NO__________ List current and past criminal history, including any arrests whether convicted or not: _____________________________________________________________________________________________ _____________________________________________________________________________________________ Do you have any pending criminal charges? YES_________________ NO______________________ If yes, give full details:___________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com _____________________________________________________________________________________________ Your attorney’s name:____________________________________________ Phone #________________________ Parole / Probation Officer’s name: _________________________________________________________________ Have you ever been on House Arrest before? ___________________ If yes, who with ________________________ _____________________________________________________________________________________________ REFERENCES: List three (3) people who you are not related to and have known you for at least one (1) year. Name______________________________________________ Occupation_________________________________ Address ____________________________________________________ Phone #___________________________ Relationship________________________________________ Name ______________________________________________ Occupation________________________________ Address ____________________________________________________ Phone #___________________________ Relationship ________________________________________ Name_______________________________________________ Occupation________________________________ Address_____________________________________________________ Phone #__________________________ Relationship ________________________________________ EMERGENCY CONTACT: (List Cohabitant who lives with you) Name__________________________________________________ Date of Birth___________________________ Address______________________________________________ Phone #__________________________________ Race _____Sex _____Height _____Weight _____Eyes ______Hair______ Place of Birth________________________ Relationship_______________________________________ I hereby certify that the statements and information herein are true and correct. I realize that falsification may result in the denial of this application for the any and all Programs offered. ___________________________________________________ Participant Signature _________________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com