Surname

First Name

Date of Birth

Main Phone Number

Cell Phone Number

E-Mail Address

Applying for ?
Select OnePardonWaiverRecord DestructionDischarge

Date of last court appearance ? (MM/DD/YYYY)

Judgement
Select OneAbsolute DischargeAcquittedConditional DischargeDismissedGuilty - Time ServedGuilty - Fine PaidNot GuiltyPeace BondStayedWithdrawnWithdrawn - DiversionWithdrawn - Peace BondQuashedUnknown

Additonal Comments / Information