REQUEST TO RESTRICT RECORD

SECTION ONE - APPLICANT INFORMATION (Completed by Applicant)

Warrant #/Court #:

Name: *

Date of Birth: *

Social Security Number: *

Race:

Telephone Number: *

Gender: *

Email: *

Street Address: *

City: *

State: *

Zip Code: *

Arresting Agency: *

Date of Arrest: *

Offense(s) Arrested For: *

Were you convicted/found guilty/pleaded guilty/pleaded nolo? *

If so, what was your sentence?

Do you have a copy of the final disposition? *

If so, please upload a copy of the final disposition here. (Optional)

Click or drag a file to this area to upload.

If you were given first offender probation, do you have a copy of the discharge order? *

If so, please upload a copy of the discharge order here. (Optional)

Click or drag a file to this area to upload.

Acknowledgement *

I acknowledge that the information provided is true and correct and that I am voluntarily submitting this form.

Signature *

Date of Signature *

Government-issued identification (Optional)

Click or drag a file to this area to upload.

Success! Your Form has been submitted.

There was an error trying to send your message. Please try again later.

District Attorney Record Restriction Form