2. First Name*
3. Last Name*
5. Email Address*
6. Phone Number*
8. Participant is the same as above

   1. Yes
10. Participant First Name
11. Participant Last Name
13. IMPORTANT NOTE:

    The Participant first and last name must match the First and Last name fields at the top of this form.

    
    

    ---

15. Last Four Digits of Your Social Security Number*
17. Date of Birth*
    Date of Birth
19. Maiden Name
21. Gender*
23. Race*
25. Street Address*
27. City*
28. County*
29. State*
30. Zip code*
32. What is the best way to reach you?*

    1. Phone
    2. Text
    3. Email
36. Are you currently on probation or parole in any county (misdemeanor, felony, or non-reporting)?*

    1. Yes
    2. No
38. Please enter any additional information
40. Do you have a pending criminal case in any jurisdiction?*

    1. Yes
    2. No
42. Please enter any additional information

    ex. County, city, charges, etc.

44. Have you ever been arrested outside of the state of Georgia?

    1. Yes
    2. No
46. Please enter any additional information
50. Consent*

    I hereby give my consent for the Athens-Clarke County Second Chance Desk Partners (the Athens-Clarke County Solicitor General's Office or the District Attorney's Office) to retrieve my Georgia Crime Information Center (GCIC) criminal history under purpose code U for purposes of reviewing my record to determine restriction (restriction and sealing) eligibility. I understand that my GCIC criminal history will be shared with the Georgia Justice Project (a non-profit law firm) for review and consultation at the Athens-Clarke County Second Chance Desk.

    This authorization is valid for 365 days.

    1. I consent
52. Limited Scope Representation*

    Georgia justice Project (GJP), a non-profit organization, will be my attorney for purposes of receiving and reviewing my GCIC criminal history report in preparation for my appointment at the Athen-Clarke County Second Chance Desk. GJP will not disseminate or share my GCIC report beyond staff or volunteers assisting with the Athens-Clarke County Second Chance Desk without my permission. GJP will not become my attorney for any other purpose absent a fully signed representation agreement between me and the Georgia Justice Project.

    1. I have read and understand
54. Digital Signature

    Please type your name

55. Date
    Date
57. Notes for Applicant

    If you have any of the following documents, please bring them to your appointment:

    • Case documents for charges you want expunged
    • Case documents for other charges on your record
    • Job or housing denials due to your record
    • Denials or communications from occupational licensing boards
    • Prior requests to clean up your record
Leave This Blank:


59. Submit

* indicates a required field