USE THE TAB KEY TO MOVE TO NEXT ANSWERProbation Officer (Choose One): Select One Brigette Beckman Denise DaVilo Nicole Ebersole Mike Jones Matt Kurowski Stacy Noble Brian Peterson Do Not Know 1. Name: Phone: Address: City or Town: State or Province: Zip or Postal Code: Who lives with you? How long have you lived at this address? Any move planned? (Type Yes or No): If so, when and where? Do you own a vehicle? (Type Yes or No) Vehicle Year, Make, Model, Color: License plate number: Do you have a valid driver’s license? (Type Yes or No) Person vehicle is registered to: 2. Are you working (Type Yes or No): If "No", go to 2A Where are you employed? Date Hired (MM/DD/YY): Salary: Number of days worked in past 4 weeks? Shift (Type 1st, 2nd, 3rd, Part-time): Reason for any absence from work: 2A. Unemployment supported by (Type in: Public aid , Unemployment comp. , Family , or Friends): 3. Are you attending school? (Type Yes, No) School name: What are you studying? If you have received grade reports, been suspended or absent during the past 4 weeks, explain: 4. Are your fines, costs or restitution paid? (Type Yes or No) (If "Yes", go to 5) If no, Last Payment Date (MM/DD/YY): Amount Owed: 5. Are you attending counseling, treatment? (Type Yes or No) (If "No", go to 5B) Counseling/Treatment Agency: Counselor's Name: Last appointment (MM/DD/YY): Next appointment (MM/DD/YY): 5B. Are you attending A.A or N.A? (Type Yes or No) (If "No", go to 6) How often? 6. List any other special conditions ordered by the court: Explain what you have done in the past 4 weeks toward fulfilling these conditions: 7. Have you been ticketed, arrested, involved in an accident, or charged with any new offenses during the past 4 weeks? (If "No" go to 8) If so, where? For what? When arrested or charged (MM/DD/YY): Date you go to court (MM/DD/YY): 8. Who have you spent most of your time with the past 4 weeks? If you have any questions or concerns, submit with this form or call for an appointment.Questions or concerns: I certify the above information to be true and correct and I understand that any falsification of my answers is a violation of my court ordered Probation/Supervision.Signature:Today's Date (MM/DD/YY):