Fill and Sign the Ohio Parole Board Application for Executive Clemency Odrc Form

HAVE YOU APPLIED FOR CLEMENCY IN THE PAST? - If yes, when:Ohio Parole Board Application for Executive Clemency APPLICANT' S NAME: DATE OF BIRTH: AGE: SOCIAL SECURITY NUMBER: TYPE OF CLEMENCY REQUESTED (SELECT ONE): INSTITUTION: ADDRESS: STREET CITY STATE ZIP ALIAS: DATE ADMITTED: INSTITUTION NUMBER: PAROLE/PRC ELIGIBILITY DATE: EXPIRATION OF DEFINITE SENTENCE: DATE RELEASED ON PAROLE/PRC: FINAL RELEASE DATE: DATE GRANTED COMMUNITY CONTROL/PROBATION: DATE COMMUNITY CONTROL/PROBATION COMPLETED: 1. 2. 3. 4. 5. 6. 7. 8. 9. IF Confined: IF NOT Confined: OR Pardon Commutation YES NO Reprieve MARITAL STATUS: SPOUSE'S NAME: NO. OF DEPENDENTS: EDUCATION: ARREST RECORD: EMPLOYMENT HISTORY: (PAST FIVE YEARS) EMPLOYER ADDRESS TELEPHONE NUMBER EMPLOYMENT STATUS DRC3068 (REV. 08/12) TELEPHONE #: CELL PHONE #: EMAIL: COUNTY (CITY) CASE NO. CRIME DATE CONVICTED SENTENCE REQUESTING CLEMENCY No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes IF PREVIOUSLY INCARCERATED, LIST INSTITUTION NUMBER: 11.NEED FOR CLEMENCY: 12. ATTACHMENTS: (LETTERS IN SUPPORT, COURT PAPERS, DIPLOMAS, ETC .)(SEE INSTRUCTIONS) I HEREBY SWEAR THAT THE INFORMATION CONTAINED IN THIS APPLICATION AND THE ATTACHED DOCUMENTS IS TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE: APPLICANT’S SIGNATURE DATE IF PREPARED BY ATTORNEY: 10. COMMUNITY/VOLUNTEER SERVICE: (SEE INSTRUCTIONS) ATTORNEY’S NAME ADDRESS ATTORNEY’S SIGNATURE DATE DRC3068 - BACK * The application, along with the attachments will be provided to the sentencing court and/or prosecuting attorney's office in the county of conviction, if requested. DISPARATE SENTENCE EMPLOYMENT OPPORTUNITIES LICENSING/BOARD EXAMS/PUBLIC OFFICE VOLUNTEER OPPORTUNITIES DEPORTATION MEDICAL OTHER: