Community Service Registration Court Services Community Service Registration Step 1 of 6 16% Name* First Middle Last Case Worker*SelectAngela DuursmaJonathan LandonBrenda McWatersJose RegalSandy BoyerRyan BrundageDate of Birth* Month Day Year Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Cell Phone*Work PhoneEmail Probation/Parole Officer Name* Discharge DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 EmploymentAre you employed?* Yes No How long have you been employed? Type Full Time Part Time Present Employer Name Position or Type of Work* Current Work ScheduleList your normal work hours for each day of the week.MONTUESWEDTHURFRISATSUN EducationLevel of Education GED Some High School High School Graduate Some College College Graduate Post Graduate Are you currently attending school? Yes No Name of School Currently Attending Field of Study Current School ScheduleList your normal school hours for each day of the week.MONTUESWEDTHURFRISATSUN AvailabilityBest Times and Days to do Community Service*Enter hours you are available.MONTUESWEDTHURFRISATSUN In Case of EmergencyEmergency Contact Name* Emergency Contact Phone*Relation to Emergency Contact* Work Assignment QuestionnaireThe type of community service work assignment will depend on many factors. To help us find the most suitable community service site for you, please complete the following.Number of Hours to be Completed* Have you done community service before?* Yes No Did you finish the hours? Yes No Where were you assigned? Do you already know of an organization where you would like to be assigned? Yes No Which organization? Which is most important in choosing a work site? Location Schedule Type of Work Do you have any medically documented physical limitations, restrictions or conditions that would interfere with your ability to do the Community Service hours?* Yes No Describe* How will you get to Community Service?* Own Vehicle Ride Bike Bus Walk For which offense were you ordered to do Community Service, please give details of the offense:*Have you had any prior convictions?* Yes No List criminal history below: List any misdemeanor convictions with dates below: List any felony convictions with dates below: I am experienced in the following areas:Check as many as you wish. Janitorial Maintenance Construction Painting Carpentry Filing Typing Sales Food Services Computers Other experience, training, or certification: CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
