I HAVE READ OR HAD READ TO ME THE ABOVE INFORMATION, AND I FULLY UNDERSTAND ITS CONTENTS.
___________________________________________________
Defendant
___________________________________________________
Surety
Witness _________________________
Date ___________________________
This application is to be filled out by any person placed on bail.
INFORMATION
Name ___________________________________ Telephone No. __________________
Alias ___________________________________________________________________
Address ________________________________________________________________
With Whom Living ________________________________________________________
Relationship to this Person ___________________________________________________
Charges ________________________________________________________________
Prosecutor ______________________________________________________________
Single ( ) Married ( ) Separated ( ) Divorced ( )
ADDITIONAL PERSONAL INFORMATION
Date of Birth _______________ Race _____________ Male ______ Female _____
Weight __________ Height _________ Build __________
Color of Eyes _____________ Eyeglasses: Yes _____ No ______ Color of Hair ________
Length of Hair __________ Bald: Yes _____ No _____Partly Bald: Yes ______ No _____
False Teeth: Yes _____ No _____ Describe any physical handicaps: _______________
______________________________________________________________________
Scars: Yes _____ No _____ If yes, describe ____________________________________
Tattoos: Yes _____ No_____ If yes, describe ___________________________________
Facial Marks: Yes _____ No _____ If yes, describe ______________________________
List Previous Convictions: ________________________________________________
Social Security No._____ - ______ - _______ Driver's License No._________________
Motor Vehicle Registration No. ___________________ State of Issuance ____________
State Your Source of Income: ______________________________________________
Employer's Name and Address: _____________________________________________
If unemployed, list last employer and address ___________________________________
______________________________________________________________________
If on Public Assistance, Claim Number _______________________________________
If not on Public Assistance, but have Medical Card,
Medical Card No. _______________
If on Unemployment Compensation, State Claim Number __________________________
Are you under order to pay support? Yes _____ No _____
If yes, what court and for whom? ____________________________________________
______________________________________________________________________
Have you ever been on bail before? Yes _____ No _____ If so, what court? ___
______________________________________________________________________
Do you have any bank accounts? Yes _____ No _____ If yes, name of bank and
address: _______________________________________________________________
Have you ever been a patient in a Mental Institution? Yes _____ No _____
If yes, where and when? ___________________________________________________
Are you addicted to alcohol? Yes _____ No _____ Have you ever received
treatment for this addiction? Yes _____ No _____ If so, where and when? _____________
_____________________________________________________________________
Are you addicted to drugs? Yes _____ No _____ Have you ever received
treatment for this addiction? Yes _____ No _____ If so, where and when? _____________
_______________________________________________________________________
State the names and addresses of any other relatives living in
_______________________________________________________________________
_______________________________________________________________________
(In addition to the Application for Bail, the following information should be obtained from the person posting the Cash Bail and should be attached to the Application for Bail of the defendant.)
Client's Name _____________________________________ No. _______________
Name of third party posting bond _________________________________________
Address _____________________________________ Telephone ______________
Occupation ________________________ Employer _________________________
Employer's Phone No. ___________________
( ) Own Resident ( ) Rent Residence ( ) Own Other Real Estate
If Yes as to Other Real Estate, describe _____________________________________
___________________________________________________________________
Mortgage held by ______________________________________________________
Date of Birth _______ Race _________ Male _______ Female _______
Weight ____ Height_______ Build _____
Color of Eyes _______ Eyeglasses: Yes _____ No _____
Color of Hair _______ Length of Hair __________________
Bald: Yes _____ No _____ Partly Bald: Yes _____ No _____
False Teeth: Yes _____ No _____
Describe any physical handicaps: ___________________________________________
____________________________________________________________________
Scars? Yes _____ No _____ If yes, describe
Tattoos? Yes _____ No _____ If yes, describe _________________________________
( ) Own Automobile ( ) Automobile Financed by _______________________________
Title __________ Plate _____________ Year ______________
Make ______________ Model ____________________________________________
Amount deposited by third party ___________________________________________
Defendant ________ Others ______________________________________________
Have you ever been on bond before? Yes _____ No _____
If so, what court? _______________________________________________________
Do you have any bank accounts? Yes _____ No _____
If yes, name of bank & address: ____________________________________________
Have you ever been a patient in a Mental Institution?
Yes _____No _____ If yes, where and when? _________________________________
Are you addicted to alcohol? Yes _____ No _____
If Yes, have you received treatment for this addiction? Yes _____ No _____
If so, where and when? ___________________________________________________
Are you addicted to drugs? Yes _____ No _____
Have you ever received treatment for this addiction?
Yes _____ No _____ If so, where and when? __________________________________
State the names and addresses of any other relatives living in Mercer County:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Additional Information: ___________________________________________________
_____________________________________________________________________
_____________________________________________________________________