Name:

Phone Number:

Email Address:

Business Phone

Cellular or Pager

Address

City

State

Zip

Booking #

Driver's License #

Court Date

Time

Court Name

Division/Room

Arresting Officer's Name and Badge

City of Arrest

What were you arrested for (include Code section)?

Have you been convicted of a similar crime before?
Yes   No 

If yes, when?

Have you been convicted of other offenses?
Yes   No 

If yes, what and when?

Are you on probation or parole?
Yes   No 

For what?

Do you have any other cases pending?

Was anyone else arrested?
Yes   No 

If so, name(s) of all persons arrested

What statements do you remember making to the police about the alleged crime?

Describe the order of events leading up to the arrest

Have you discussed the alleged crime with anybody else?
Yes   No 

If so, who did you discuss it with and what did you tell them?

Were there any witnesses to the alleged crime?
Yes   No 

If yes, provide names and contact information if known

What is the amount of the bond you posted?

Are there any special bond conditions

Were you referred by somebody else
Yes   No 

Who

Special concerns