Registration/Application for Work Release
asd email
Case Details
Status
New / Unassigned
Assigned
Start Date Set / Email Packet
Start Date Set / Email Packet - Completed Over the Phone
Start Date Set - Completed in Person
No Start Date Given
Case Mgr
--please assign case manager
Sandi Bishop
Keelia Conrad
Zach Johnson
Kirk Kearney
Jennifer Koenig
Nicole McCune
Christina Vannest
Lori Whitson
Case Mgr Email
Pop Up Calendar
WR TIME
10AM
2:30PM
WR Time
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15
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45
PM
AM
COVID Test Required
Yes
No
Covid Test Date
ES
Spanish
Name (Firstname, Lastname)
Lastname
Para español, haga clic aquí
Printed Name
Date of Birth
January
February
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April
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2020
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2022
2023
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2025
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2027
2028
2029
2030
Gender
Male
Female
Gender Diverse
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
Cell Phone
Other Phone
Phone:
Email Address
no email
No Email
Case Number
Charge
Judge
Date Sentenced
Employer (if employed)
School (if attending school)
Please list any religious or medical dietary needs/restrictions
Please list any prior convictions in the last five years
Expedited Booking
Requesting to come into custody ASAP
Why are you requesting to come into custody ASAP?
Offender Signature
Date Field
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
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30
31
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
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1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
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2008
2009
2010
2011
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2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Staff Signature
staff sign date
Register / Submit Form
Reset
PDF File
PDF File
PDF File
PDF File
