Fill and Sign the Applications Must Be Typewritten or Clearly Printed All Form

Rev. 11-2008 1 VERMONT PARDON APPLICATION (This form must be completed by all pardon applicants.) Applications must be typewritten or clearly printed. All questions must be answered, if applicable; if not, indicate by N/A (not applicable). If the space provided is not sufficient for complete answers, or if you wish to furnish additional information, attach sheets and number answers to correspond with questions. This application must be signed in the presence of a notary public. 1. Full Name: 2. Address: 3. Telephone #: 4. Social Security #: 5. Date of Birth: 6. Place of Birth: 7. Male/Female: 8. Marital Status: 9. Number of Children: Ages: 10. For every conviction you would like to have consider ed for a pardon, provide the following (attach a separate sheet if more space is needed): a. Date of conviction: Felony or misdemeanor: County of conviction: Court Docket No.: Criminal offense: Sentence (amount of fine and/or jail time): b. Date of conviction: Felony or misdemeanor: County of conviction: Court Docket No.: Criminal offense: Sentence (amount of fine and/or jail time): c. Date of conviction: Felony or misdemeanor: County of conviction: Court Docket No.: Criminal offense: Sentence (amount of fine and/or jail time): Rev. 11-2008 2 11. Please describe the circumstances of each offense and conviction for which a pardon is sought (attach a separate sheet if more space is needed). 12. Have you requested a pardon before? If yes, when? 13. Why are you requesting this pardon: Employment ______ Entry into Service ______ Other (explain) 14. Please briefly describe the reasons for this par don request. A lengthier explanation and supporting documentation may be attached. EDUCATION AND TRAINING 15. Highest Grade Completed: 16. Name of School: MILITARY SERVICE 17. Branch of Service: 18. Service Number: 19. Type of Discharge: 20. Dates of Active Duty: From To EMPLOYMENT 21. Present Place of Employment: 22. Address and Telephone Number: 23. How Long? 24. Kind of Work? 25. Previous Employment and Dates: GENERAL INFORMATION 26. Have you been convicted of any offenses (including mo tor vehicle violations) in Vermont or another state SINCE the conviction for which you are requesting a pardon? YES NO Rev. 11-2008 3 27. If the answer to number 26 above is YES, provide the following details for each offense: the date of conviction, the offense and sentence imposed, and the State and Court in which convicted (attach a separate sheet if more space is needed). 28. Have you ever been arrested by federal aut horities, or by any other state or local authority OTHER THAN IN VERMONT ? YES NO 29. If the answer to number 28 above is YES, provide the following details for each arrest: the date of arrest, the offense and sentence imposed, and the State and Court in which convicted (attach a separate sheet if more space is needed). 30. Do you have a specific and compelling need for a pardon? YES NO 31. What is that need? 32. Petitioners must demonstrate a substantial period of good citizenship and an exemplary life since conviction. Please indicate examples of constructive conduct and specifi c achievements, if any (attach a separate sheet if more space is needed). 33. How will a pardon substantially aid you in improving your life (attach a separate sheet if more space is needed)? 34. How will a pardon benefit society? REFERENCES 35. Please provide four letters specifically in support of your pardon application, from persons other than you or members of your family, attesting to your good charac ter and reputation. Please list the names of such individuals below. Name Address Telephone # Relationship Rev. 11-2008 4 36. I hereby certify that the information submitted in this application is true, accurate, and complete to the best of my knowledge. By submitting this applicat ion, I understand that I am agreeing to release of my motor vehicle record and consenting to public rel ease of my name should a pardon be issued. Signature (must be signed in the presence of a notary public) Date STATE OF ) ) ss. COUNTY OF ) Sworn to before me this day of , 20 . Notary Public: My Commission Expires: ************************************************************************************************** *** MAIL YOUR COMPLETED APPLICATION TO : Office of the Governor, 109 State Street, The Pavilion Montpelier, VT 05609-0101 TO BE DEEMED COMPLETE, YOUR APPLICATION MUST INCLUDE : 1. a response to each question, 2. at least four letters of reference specifica lly supporting your pardon application, and 3. signature before a notary public.