JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Clean Slate Project Application
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name (First, Middle, Last)
*
Your answer
Phone Number
Your answer
Race
*
Your answer
Legal Gender
*
Male
Female
Marital Status
*
Single (never married)
Married
Domestic Partnership
Divorced
Widowed
Date of Birth
*
MM
/
DD
/
YYYY
Primary Language
*
English
Spanish
Other
Driver's License number (if applicable):
Your answer
Home address at time of incident:
Your answer
Please list any former names or aliases
Your answer
Criminal Charge(s) – include case numbers and date of offense. If you are unsure of your case number(s), please at least make sure that you provide the charge received, the date, and the County you received it in.
*
Your answer
County of Offense (MUST BE IN TEXAS):
*
Your answer
Case Outcome (select all that apply)
*
Prison
County Jail
Probation
Deferred Adjudication
Reduction
Dismissal
Refusal
Unknown
Required
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Scorpion.
Report Abuse
Forms
