Page 1 of 2 Revised 4/5/18 IN THE CIRCUIT COURT FOR DAVIDSON COUNTY, TENNESSEE PETITION FOR CERTIFICATE OF EMPLOYABILITY [Pursuant to T.C.A. 24740-29-107] NAME: DATE OF BIRTH: ALIAS(ES): ADDRESS: (Street) (City) (State) (County) (ZIP) PHONE #: LENGTH OF RESIDENCE IN TN: Years Months SOCIAL SECURITY NUMBER(S) (including for alias(es)): COUNTY/COURT OF CONVICTION: County Federal: State Trial Criminal Court: CRIMINAL HISTORY (include each offense that is a disqualification from employment or licensing in an occupation or profession, including the years of each conviction or plea of guilty): EMPLOYMENT HISTORY (specify the name of each employer, position held, and dates of employment): VERIFIABLE REFERENCES AND ENDORSEMENTS: PERSON(S) WHO SUPPORT RE-ENTRY PLAN (list one or more immediate family members or other persons with whom you have a close relationship): SUMMARY OF THE REASON(S) A CERTIFICATE OF EMPLOYABILITY SHOULD BE GRANTED: Print Name Signature Date American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 Revised 4/5/18 CERTIFICATE OF SERVICE This is to certify that a true and exact copy of the foregoing Petition for Certificate of Employability has been mailed, postage prepaid, by U.S. Mail to: This day of , 20 . Deputy Clerk American LegalNet, Inc. www.FormsWorkFlow.com