COMMONWEALTH OF PENNSYLVANIA v. ________________________________________ : : : : : : IN THE COURT OF COMMON PLEAS OF ERIE COUNTY, PENNSYLVANIA CRIMINAL DIVISION NO.: _____________ OF 20_______ OTN: _________________________ APPLICATION FOR DISPOSITION UNDER PROGRAM OF ACCELERATED REHABILITATIVE DISPOSITION/PROBATION WITHOUT VERDICT Application is hereby made for disposition of this case under the Accelerated Rehabilitative Disposition/Probation Without Verdict Program. To assist the District Attorney=s Office in evaluating the suitability of this case for the ARD/PWOV Program, the following information is provided: INSTRUCTIONS: 1. 2. 3. 4. 5. Answer all questions that apply. If a question does not apply, answer it with the initials AN.A.@ Full Name of the defendant: ___ ________________________________________________________________ Maiden Name of defendant; or other names previously used: ___________________________________________ Date of Birth: ______________________ Social Security Number: ___________________________ Driver License Number: ___________________________ State Issued:________________________ Present Address: _____________________________________________________________________________ City: ____________________________ State: ______________ Zip Code: _______________ Phone (Home) ( ) __ _____ (Work) ( )____________________ 6. Previous Addresses and length of time at each (go back 10 years): _________________________________________ _______________________________________________________________________________________________ 7. 8. Present Employment: ___________________________________________________________________________________________ Education-Schools and Highest Year attained: ___________________________________________________________________________________________ 9A. Have you ever been found guilty or pleaded guilty or no contest to any criminal violation of any kind in any court other than summery offenses, whether in Pennsylvania or anywhere else? If so, explain giving date, place, charge(s), and disposition: ___________________________________________________________________________________________________ 9B. Do you have any other pending criminal charge(s) or have you ever been placed on ARD or PWOV? If so, explain giving date, place, charges and disposition: ______________________________________________________________ _______________________________________________________________________________________________ 9C. If charged with Driving Under the Influence: Have you ever been adjudicated a delinquent or entered into a coagreement as a juvenile after being charged with Driving Under the Influence of Alcohol? If so, explain giving details:______________________________________________________________________________________________ __________________________________________________________________________________________________ 10. Explanation of your present case, including all details (use reverse side if needed):_____________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 2 ___________________________________________________________________________________________________ 11. By applying for ARD/PWOV and by signing this application I acknowledge, certify, and understand each of the following rights and responsibilities: A. I have been advised and I understand that I have a constitutional right to a speedy trial; that pursuant to Pa.R. Crim. P. 1100, the Commonwealth must bring my case to trial within 365 days from the date of the filing of the Criminal Complaint charging me. If my case is not brought to trial within 365 days from the filing of the Criminal Complaint, I understand I can ask the Court to dismiss all charges against me. Furthermore, I understand that in the event I am incarcerated on these charges, the Commonwealth must bring my case to trial within 180 days from the date of the filing of the Criminal Complaint, if the Commonwealth fails to do so, I can ask the Court for nominal bail. I hereby waive (give up) all of my constitutional rights to a speedy trial as set forth from the date I sign this Application until I either complete the ARD Program or am revoked from it, should I violate the conditions the Court imposes on me. In the event my Application for ARD is denied, I waive (give up) all of my constitutional rights to a speedy trial as set forth from the date I sign this Application until the last scheduled day of the term o f Criminal Court next following the date of my rejection. I have been advised and I understand that by signing this waiver I am waiving (giving up) any and all rights I may have to be tried within 180th (if in jail) or 365th day following the filing of the Criminal Complaint against me. I am signing the waiver because I understand it is to my benefit to do so and to allow the District Attorney as much time as he needs to evaluate my suitability for the ARD Program. I have not been made any promises, nor have I been forced or coerced to sign this waiver. B. I understand I have the right to be represented by an attorney on my charge(s) and also in connection with my ARD/PWOV Application. If I cannot afford counsel, the Court will provide me free counsel through the Erie County Public Defender=s Office. C. It is my responsibility to notify the District Attorney=s Office, in writing, of my arrest and/or conviction for any offense occurring after this Application is made and before it is rejected or I am accepted into the Program by the Court. Failure to comply with this requirement is grounds for refusal of the Application and/or may be treated as a false statement subjecting me to prosecution and/or for removal from the Program. D. If charged with Driving Under the Influence: I understand that it is my responsibility to arrange for a CRN evaluation. I understand that I cannot be placed in the ARD Program unless such evaluation is completed. I further understand that I am to contact \DUI Program, 1306 East Lake Rd, Erie, PA 16507 at (814)454-3326 between 8:30 a.m. and 3:30 p.m. to arrange an appointment. E. I acknowledge that I have completed (or will complete prior to my ARD hearing) all processing (e.g. Fingerprinting, etc.) required by me. I understand that failure to do so may delay my acceptance into the program. F. The information I have provided above is true and correct. I understand if I have provided false information on this Application, that reason alone is suf