Restoration of Civil Rights

Name of applicant as convicted:

Ethnicity (Select one from box.)

Have you ever declared bankruptcy? If "Yes," provide the name of the court and the year your debt was discharged:

Employer Name:

Supervisor:

Employer Address:

Phone Number

Requested Action:

Please explain if there is a specific need for the right to bear arms to be restored, or if you are requesting a pardon without the restoration of the right to bear arms, please explain why.

Please explain if you have an extraordinary need for a Pardon:

If "Yes," enter the year of completion

Name of Sentencing Judge:

Sentence Date:

If "Yes," enter the year of completion

Name of Sentencing Judge:

Sentence Date:

Signature:

Printed/Typed Name:

Date:

(print or type)

This is to certify that I have applied for a pardon and the restoration of my civil rights and acknowledge that an investigation will be conducted prior to my case appearing before the Nevada Board of Pardons Commissioners (Pardons Board). In consideration for the processing of my application, I, , do hereby agree to the following:

WAIVER OF LIABILITY AND INFORMATION TO BE RELEASED:

Having made application to the Pardons Board and desiring it to be informed as to my record and character, I authorize and desire the release of any information, verbal and/or written, which includes but is not limited to information related to current or previous employment, personnel records, criminal records, educational records, any investigative records, credit records, tax or bank records, correctional records, sealed records, confidential records or information previously agreed to be withheld, medical records, mental health records, opinions of my character or conduct, and any and all information that a person or entity may have concerning me, and I agree to hold all entities and persons whomsoever from any liability because of furnishing said information.

INFORMATION TO BE RELEASED FROM:

Any person or entity who may have knowledge of the above named individual including but not limited to friends, family members, neighbors, acquaintances, co-workers, businesses, previous or current employers, any law enforcement or corrections agency, any mental health or medical organization, clinic, physician, laboratory, pharmacy, hospital, inpatient or outpatient program or facility, any credit reporting bureau, any educational facility or institution, any financial institution, or any other person or entity deemed relevant by the agency or person conducting the background investigation incident to my application for pardon and restoration of civil rights, may furnish said information.

INFORMATION TO BE RELEASED TO:

The Nevada Department of Public Safety, the Nevada Division of Investigations, the Nevada Division of Parole and Probation, the Pardons Board, the Nevada Department of Corrections, the Nevada Criminal History Repository, the Nevada Board of Parole Commissioners, the office of the Nevada Attorney General, the Nevada Supreme Court, the office of the Governor of the State of Nevada or any other person, department or agency inside or outside the State of Nevada involved with gathering information during the conduct of the investigation incident to my application for pardon and restoration of civil rights, may receive said information.

PURPOSE OF RELEASE:

I, the above named applicant, have requested a pardon and the restoration of civil rights. The members of the Pardons Board may consider a wide range of factors including my character, conduct, criminal record, mental or medical health status and any other significant history about me incident to such application for clemency.

I understand that my authorization under this Waiver and Liability Release is voluntary and that I may refuse to sign this document. I understand that I am not entitled to receive or examine, review or otherwise discover the contents of the information gathered or disclosed in the course of the investigation incident to my application for pardon and restoration of civil rights. I understand that if I refuse to sign this authorization document, my application for pardon and restoration of civil rights will not be considered. I understand that information gathered may become public record if the subject application is brought for consideration at a meeting before the Pardons Board. I understand that I may revoke this authorization under this Waiver and Liability Release at any time by notifying the Pardons Board in writing at 1677 Old Hot Springs Rd., Suite A, Carson City, NV 89706, except to the extent that action has taken place in reliance on this authorization document. I understand that any such revocation of authorization will result in the termination of any pardons investigation or termination of further consideration for clemency. This waiver shall apply to any right of action of any nature whatsoever, that may accrue to myself, my heirs or my personal representative(s).