Fill and Sign the Judgment Conviction Form

APPLICATION FOR ACCEPTANCE INTO THE PRETRIAL INTERVENTION PROGRAM OF THE TWENTIETH CIRCUIT COURT DISTRICT 1. NAME: ________________________________________________________ FIRST MIDDLE LAST ADDRESS: _____________________________________________________ PHONE: ________________________________________________________ HOME WORK 2. RACE: ____________ SEX: __________ DATE OF BIRTH: _______ HEIGHT: ______ WEIGHT: _____ EYES: _________ HAIR: _____________ PLACE OF BIRTH: _______________________________________________ 3. SOCIAL SECURITY NUMBER: ____________________________________ 4. I have been indicted in the Circuit Court of ___________ County, __________, in Cause No. ___________ for the crime of: __________________________________________ 5. I am represented by attorney __________________ whose address is _______________and whose telephone number is _____________________________. 6. I have not previously been accepted into an intervention program. 7. I am not charged with a crime of violence including, but not limited to murder, aggravated assault, rape, armed robbery, manslaughter or burglary of a dwelling house. 8. I am not charged with: (a) an offense pertaining to the sale, barter, transfer, manufacture, distribution or dispensing of a controlled substance, or the possession with intent to sell, barter, transfer, manufacture, distribute or dispense a controlled substance, as provided in Section 41-29-139 (a) (1), Mississippi Code 1972 Annotated, as amended; except for a charge under said statute when the controlled substance involved is one (1) ounce or less of marihuana; or (b) an offense pertaining to the possession of one (1) kilogram or more of marihuana as provided in Sec. 41-29-139 (c) (2) (D), Mississippi Code 1972 Annotated, as amended. 9. My past criminal history is as follows (include delinquency and Juvenile record): _______________________________________________________________________. 10. My educational background is as follows: _____________________________________ _______________________________________________________________________ 11. My work record is as follows: _______________________________________________ _______________________________________________________________________ 12. My family history is as follows: _____________________________________________ 13. My medical treatment is as follows: _________________________________________. 14. I have undergone psychiatric treatment or care as follows: ________________________ _______________________________________________________________________. 15. I have attached a copy of any and all psychological tests taken by me. 16. My drug use is as follows: __________________________________________________ 17. My drug treatment is as follows: _____________________________________________ 18. If directed to do so by the District Attorney, I agree to submit to an evaluation. 19. I waive my right to a speedy trial as guaranteed by the United States Constitution, the Constitution of the State of __________, and all pertinent statutes of the State of __________, contingent upon my successful completion of this program, if accepted. 20. I agree to waive extradition to ______________ County, __________, from any other State of the United States or any other Country. I further agree not to contest any request for my return to said County, State of __________. 21. I hereby agree to obey and abide by any and all conditions, rules and regulations prescribed by the District Attorney's Office while in the Pretrial Intervention Program, if accepted. 22. I further agree and understand that if accepted into the Pretrial Intervention Program, If I should violate the conditions of the Agreement: (a) the District Attorney may terminate my participation in the program; (b) the Waiver executed pursuant to Section 99-15-115, Mississippi Code 1972 Annotated, as amended, concerning the right to a speedy trial and the tolling of the periods of limitation established by statutes and/or rules of Court shall be void on the date I am removed from the program for the violation; and (c) the prosecution of pending criminal charges against me shall be resumed by the District Attorney. I hereby affirm that the information provided above is true and correct. Further, I understand and agree to abide by the conditions set forth above, if accepted into the Pretrial Intervention Program. This the _________ day of __________ _______. ____________________________ APPLICANT APPROVED: ____________________________ APPLICANT'S ATTORNEY