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IN THE COURT OF COMMON PLEAS OF CENTRE COUNTY, COMMONWEALTH OF : OTN # : v : : : CP-14-CR- - (name of applicant) APPLICATION FOR DUI COURT To the District Attorney of Centre County (May also be submitted to the PROBATION DEPARTMENT) I, , defendant in the above-captioned case, request that the District Attorney of Centre County submit said case to a judge of the Court of Common Pleas of Centre County and move that it be considered for DUI Court Disposition. I understand that under Rule 600 of the Rules of Criminal Procedure I have a right to have my case tried within 365 days from the date of the filing of the Criminal Complaint. I hereby agree to waive this right from the date of this application until the date of receipt of written approval. If this application is rejected, I agree to waive my 365 day trial right from the date of this application until the completion of the term of court next following the date of my notice of rejection. I also understand that I have a right to be represented by an attorney. In furtherance of this application I am submitting the information contained in the attached questionnaire with the intent that it be used by the District Attorney of Centre County to determine my eligibility for DUI Court. Signature of Defendant Date *Submit all application materials prior to the Pre-Trial Conference Date listed on your IMPORTANT NOTICE. To be completed by the District Attorney Received on: Restitution Due YES NO Municipal Fee YES NO District Attorney Signature Date Approved Denied Reason: ---PAGE BREAK--- 2 INSTRUCTIONS FOR COMPLETING APPLICATION This application must be completed by the person named as the Defendant in the above-captioned case. All questions must be answered fully and truthfully. If you are uncertain of any of the answers provided, please explain. False or misleading answers may result in the denial of your Application for DUI Court as well as constitute a criminal offense. By signing this application, you are agreeing to enter into a payment contract with the Centre County Probation/Parole Department in order to satisfy the outstanding balance prior to release from Probation supervision. Payments are expected in the full amount on a basis. Failure to abide by the payment contract may result in termination from the program. The Court will NOT accept any excuses if the balance is not paid, and you will not receive a refund. *This application must be submitted by the Pre-Trial Conference date listed on the IMPORTANT NOTICE you/your attorney received at the time of your Preliminary Hearing. Failure to submit all application materials prior to this date will disqualify you from consideration for the DUI Court program. Upon completion, this application can be submitted to the Centre County Probation/Parole Department or forwarded to the District Attorney of Centre County, 106 East High Street, Room 302, Bellefonte, 16823. If you would like to be considered for work release from the Centre County Correctional Facility during your period of incarceration, you must contact the Work Release Coordinator at (814) 355-6794 at least two weeks prior to going to jail. A copy of the work release application can be found at the District Attorney’s website: www.centreda.org. Be advised, you will be drug tested prior to work release and will not be released until a negative test result is achieved. PERSONAL DATA Name Current Address Permanent Address Employer’s Name Employer’s Address Length of Employment Home Telephone Number - - Work Telephone Number - - Social Security Number - - Date of Birth - - Place of Birth ---PAGE BREAK--- 3 PREVIOUS ADDRESSES List all addresses, other than those set forth above, where you have resided for the past ten (10) years: Address Years of Residence To Address Years of Residence To Address Years of Residence To CURRENT OFFENSE Offense(s) for which Application for DUI Court is made: Other Offenses charged: Date of Offense(s) Prosecuting Officer Your Attorney’s Name Phone # Please answer all of the following: Did you submit to a blood, breath or urine test to determine your blood alcohol content? If so, what was the result? Were you involved in an automobile accident? If so, please describe: ---PAGE BREAK--- 4 If you were involved in an automobile accident, did any person other than yourself su stain any physical injury or property damage? If yes, please describe: PAST CRIMINAL RECORD List all felony, misdemeanor and summary offenses for which you have ever been CHARGED: in any state in the United States including or involving federal laws and, regardless of the final disposition of the case, including ARD and juvenile adjudications. 1. Offense(s) Place where offense filed: Court State Date of disposition Disposition of offense(s): 2. Offense(s) Place where offense filed: Court State Date of disposition Disposition of offense(s): 3. List additional prior offenses below. Use extra sheets if necessary. ---PAGE BREAK--- 5 NOTICE TO DEFENDANT Section 4903 of the Crimes Code provides that “A person who makes false statements under oath…is guilty of a Misdemeanor of the Second Degree (fine not exceeding $5,000 and/or a term of imprisonment of not more than two years), if the falsification is intended to mislead a public servant in performing his official function.” AFFIDAVIT I, the undersigned, being duly sworn according to the law, depose and say that the facts stated in this application are true and correct to the best of my knowledge, information and belief, and that the statements are presented to the District Attorney of Centre County with the intent that they be used by him in the performance of his official duties and functions. Defendant’s signature