Registration/Application for Work Release
asd email
Case Details
Status
New / Unassigned
Assigned
Start Date Set / Email Packet
Start Date Set / Email Packet - Completed Over the Phone
Start Date Set - Completed in Person
No Start Date Given
Case Mgr
--please assign case manager
Sandi Bishop
Keelia Conrad
Zach Johnson
Kirk Kearney
Jennifer Koenig
Nicole McCune
Christina Vannest
Lori Whitson
Case Mgr Email
Pop Up Calendar
WR TIME
10AM
2:30PM
WR Time
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15
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45
PM
AM
COVID Test Required
Yes
No
Covid Test Date
ES
Spanish
Name (Firstname, Lastname)
*
Lastname
*
Para español, haga clic aquí
Printed Name
Date of Birth
*
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February
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Gender
Male
Female
Gender Diverse
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Cell Phone
*
Other Phone
Phone:
Email Address
*
no email
No Email
Case Number
Charge
Judge
Date Sentenced
Employer (if employed)
School (if attending school)
Please list any religious or medical dietary needs/restrictions
Preferred Language
Interpreter Needed?
Yes
No
Please list any prior convictions in the last five years
Expedited Booking
Requesting to come into custody ASAP
Why are you requesting to come into custody ASAP?
Offender Signature
Undo
signature
Date Field
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
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14
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31
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1989
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2022
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2025
2026
2027
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2029
2030
Staff Signature
Undo
signature
staff sign date
Register / Submit Form
Reset
PDF File
PDF File
PDF File
PDF File
