COMMONWEALTH OF PENNSYLVANIA v. _____________________________________ : : : : : : IN THE COURT OF COMMON PLEAS OF ERIE COUNTY, PENNSYLVANIA CRIMINAL DIVISION NO.:________________ OF 20_____ OTN:___________________________ APPLICATION FOR ERIE COUNTY TREATMENT COURT Application is hereby made for disposition of this case under the Erie County Treatment Court Program. To assist the District Attorney's Office in evaluating the suitability of this case for the Erie County Treatment Program, the following information is provided: INSTRUCTIONS: Answer all questions that apply. If a question does not apply, answer it with the initials N.A. 1. 2. Full Name of the defendant: _____________________________________________________________ Maiden Name of defendant; or other last names previously used: ________________________________ ____________________________________________________________________________________ 3. Date of Birth: ___________________ Gender (circle one): M/F 4. 5. Social Security Number: ____________________________ Race/Ethnicity: ___________________________________ Driver License Number: _____________________________ State Issued: ________________________ Present Address:_______________________________________________________________________ City: ________________________ State: ____________ Zip Code: _______________________ Phone: (Home) ( ) (Cell) ( ) Email Address: ________________________________ 6. 7. 8. 9. Present Employment: Next of Kin or Emergency Contact: Name: Work Phone ( Phone ( ) ) Education-Schools and Highest Year attained: _______________________________________________ Have you served in the Military? _______ If so, which branch? _________________________ Were you honorably discharged? _________________________ Are you eligible for services through the VA? ________ Are you enrolled in services through the VA? ________ 10. Do you have any other pending criminal charge(s)? If so, explain giving date, place, charges and disposition: ____________________________________________________________________________________ ____________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 1f3 11. Are you currently on supervision (probation or parole)? If so, explain whether it is county or state supervised and the name of your probation/parole officer: ____________________________________________________________________________________ ____________________________________________________________________________________ 12. Do you have a history of drug/alcohol abuse and/or serious mental illness? If so, give details, including any past treatment you have received (Use reverse side if needed): ____________________________________________________________________________________ ____________________________________________________________________________________ 13. Have you ever participated in a Drug Court or any other treatment court in Erie County or any other place? If so, explain which jurisdiction you participated in treatment court and during what time period. Also indicate whether you graduated/successfully completed the program. ____________________________________________________________________________________ ____________________________________________________________________________________ 13. Explanation of your present case, including all details (use reverse side if needed): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ NOTE: The information provided in this section will only be used for the purposes of evaluating this application and will not be used against the defendant in any further criminal proceedings. PLEASE SUBMIT COPY OF CRIMINAL COMPLAINT OR CRIMINAL INFORMATION WITH THIS APPLICATION. 14. By applying for ECT Program 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. 600 formerly Pa.R.Crim. P. 1100, the Commonwealth must bring my case 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 ECT Program or am revoked from it, should I violate the conditions the Court imposes on me. In the event my Application for ECT 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 of 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 180 (if in jail) or 365 days 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 American LegalNet, Inc. www.FormsWorkFlow.com 2f3 ECT 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 ECT 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. I acknowledge that I have c