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STATE OF ILLINOIS CIRCUIT COURT OF Application for Certificate of Good Conduct Case Number: Number/Street City State Zip Code Social Security Number: of Birth: Offense of Conviction: Date of Sentence: State Prisoner/Department of Corrections Number (as applicable): Pursuant to the provisions of 730 ILCS 5/5-5.5-30, application is hereby made for issuance of a CERTIFICATE OF GOOD CONDUCT to relieve the holder of any employment bar as herein enumerated: The applicant hereby affirms that he/she is an eligible offender as specified by the provisions of 730 ILCS 5/5-5.5-5. The applicant must meet minimum periods of good conduct and agree to cooperate with an investigation and a rehabilitative review to determine fitness for a Certificate of Good Conduct. Applicant Signature: Date: