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2. First Name*
4. Middle Name
6. Last Name*
8. Please list any other names you have used:
10. Date of Birth*
    Date of Birth
12. Address1*
14. Address2
16. City*
17. State*
18. Zip*
20. Email*
22. Have you been charged with a Felony offense in Blue Earth County
    -- Select One --YesNoI don't Know
24. Were you convicted of a Felony in Blue Earth County
    -- Select One --YesNoI don't know
26. Was your entire case dismissed by the Court or the Prosecutor?
    -- Select One --YesNoI don't know
28. Were you acquitted of all counts by the Court or a Jury?
    -- Select One --YesNoI don't know
30. Were you charged with a Felony but convicted of a lesser offense such as a Misdemeanor or Gross Misdemeanor?
    -- Select One --YesNoI don't know
32. Did you receive a stay of adjudication, stay of imposition, stay of execution, continuance for dismissal, deferred prosecution, reduced charge, or did you complete a diversion program?
    -- Select One --YesNoI don't know
34. Did your offense involve any victims?
    -- Select One --YesNoI don't know
36. Have you ever been named in an Order for Protection, Restraining Order, Harassment Order, or any other type of No Contact Order?
    -- Select One --YesNoI don't know
38. Were you ordered to pay restitution as part of your sentence?
    -- Select One --YesNoI don't know
40. Do you have any pending criminal charges in Minnesota or any other state?
    -- Select One --YesNoI don't know
42. Have you been denied employment as a result of your criminal record?
    -- Select One --YesNoI don't know
44. Have you been denied housing as a result of your criminal record?
    -- Select One --YesNoI don't know
46. Have you been denied any other benefit as a result of your criminal record?
    -- Select One --YesNoI don't know
48. Please explain how your criminal record has affected you:
50. Mark the offenses with which you were charged:

    Check all that apply to you.

    1. Fifth Degree Drug Possession or Sale
    2. Theft
    3. Receiving Stolen Goods
    4. Damage to Property
    5. Forgery Crimes
    6. Possession or Sale of Stolen or Counterfeit Check
    7. Mail Theft
    8. Dishonored Check
    9. Financial Transaction Card Fraud
    10. False Declaration on Assistance Application
    11. Other Offense
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52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

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