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GLOCUESTER
COMMUNITY CORRECTIONS APPLICATION
Please check the program you
wish to apply for: Electronic Monitoring Work
Release Weekender
Fully complete the
application below.
The Community Corrections program
is designed to provide the opportunity to work and receive education or
vocational training for those individuals who are accepted into the
program. Only those that are sentenced
and have no other charges pending are eligible to apply. If you are interested in participating, fill
in the information requested below and submit it to the Community Corrections
staff.
Name: (Last) (First): (Middle):
SSN: POB (City): State: DOB: Age:
Address: City: State: Zip:
Phone: (Home): ( ) Work: (
) Total number of persons living in your
household:
Height: Weight: Hair Color: Eye
Color: Tattoos/Marks:
Nationality: Marital Status: Single Married Separated Divorced Name
of Spouse:
Health: Excellent Good Fair Poor Do You have any physical or mental disabilities or
defects? Yes No
Explain: Are you taking any medications? If so what type and why?
Education: Circle the highest grade completed: 5 6 7 8 9 10 11 12 College: 1 2 3 4 Read /write: _______
Last school
attended: City: State:
List Names
of Trade, Technical, or Armed Forces schools you have attended:
Were you
employed prior to confinement: Yes No Occupation:
Current employer name: City: State: Phone:
( )
Are you
eligible for re-employment with your current employer: Yes No___
How long
have you employed there: Name of your immediate supervisor:
Work days
requested:_________________________
Transportation available by employer?
Yes ____ No _____
List Job
Skills:
List a total of four (4)
references below. If any information is
omitted, your application will be returned to you.
**List two (2) relatives
living in the
Name Relationship Address City
State Phone
Number
**List two (2) friends
living in the
Name Address City State Phone
Number
Have you ever been on
Electronic Monitoring, Work Release or the Weekender Program? Yes No
Are you on probation or
parole now? Yes No If
yes, list the name of your probation/parole officer:
All
statements have been answered truthfully to the best of my knowledge. I understand that if any of my answers
prove false, or questions have not been completed in their entirety,
constitutes grounds for my denial or dismissal from the program.
Applicants Signature: Cell Assignment: Date:
Community Corrections Staff:
#: Date:
(Page 1-2)
FAMILY BACKGROUND
Parents
Mother’s Name: Address: Phone:
Father’s Name: Address: Phone:
Siblings
Name: Address: Phone:
Name: Address: Phone:
Name: Address: Phone:
Name: Address: Phone:
Name: Address: Phone:
Name: Address: Phone:
Name: Address: Phone:
Children
Name: Address: Phone:
Name: Address: Phone:
Name: Address: Phone:
Name: Address: Phone:
Name: Address: Phone:
Name: Address: Phone:
Name: Address: Phone:
Emergency
Contact/Next of Kin:
_______________________ Relation:____________
Phone:_____________
Current Charges:____________________________________________________________________________
_______________________________________________________________________________ ______
List your hangouts/boyfriend/girlfriend/bars,
clubs/neighborhoods and any family members you frequently visit either in town
or out of town.
List Year/Make/Model/License of Personal Vehicles
(Work Release and Electronic Monitoring Applicants Only)
OFFICE USE ONLY
Release Date: Court: Sentence:
Start Date: Charge(s): Log In Date:
VCIN/NCIC: Drivers License: Counselor
Assigned:
Approved for Program: YES NO Supervisor’s Signature:
Disapproved/Reason:
Revised: 02/08