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Augusta Judicial Circuit Drug Court Referral Form Referral Date: Name of Defendant: A/K/A: D.O Social Security Referring: Source/ Attorney: Source/Attorney Phone Number: Pending Case Charge: Date of Arrest: Arrest Agency: Physical Location of Defendant: Defendant’s residence Street Address: City/Town: State: Telephone Number: Alternate Telephone Contact I have read and reviewed the “Is Drug Court for Me” brochure & the “Augusta Judicial Circuit Drug Court” flyer: Yes No Briefly tell us why you are considering Drug Court: This Completed Form Must be Faxed to: Augusta Judicial Circuit Drug Court Attn: Ted Wiggins, Drug Court Coordinator 530 Greene Street, Suite 902 Augusta, Georgia 30901 FAX#: [PHONE REDACTED] Email: [EMAIL REDACTED] Phone: [PHONE REDACTED] www.augustaga.gov