APPLICATION FOR ELECTRONIC MONITORING PROGRAM (EMP)

Applicant Name:

Date of Birth:

Address:

City:

ZIP:

County:

How Long Lived at Above Address:

Telephone #:

Cell #:

Social Security #

Sex:

Race:

Height:

Weight:

Eye Color:

Hair Color:

Scars/Marks/Tattoos, etc:

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Employer:

Address:

City:

Zip:

County:

Telephone #:

Type of Work:

Weekly Work Hours (day/time):

Length of Employment:

Does your job location vary?

Yes

No

Does your supervisor work on site with you?

Yes

No

Does your job take you out of the county?

Yes

No

Are you self-employed (proof required)?

Yes

No

Explain your transportation on how you will get to work and appointments:

Application for EMP - continued

Page 2

Marital Status (circle one)

Married

Single

Divorced

Do you rent or own residence?

List all people living with you?

Name

Age

Relationship

1.

2.

3.

4.

5.

6.

What is the current charge(s) you are in jail for?

What is the length of your sentence?

What is your scheduled release date?

Do you have any charges pending (list charges)?

1.

2.

Are you currently on probation or parole?

Yes

No

If yes, what charge(s) are you on probation or parole for?

1.

2.

3.

If yes, what is the name and phone number of your agent?

Have you ever been convicted of a domestic charge?

Yes

No

When?

Victim’s Name:

Do you have any restraining orders or injunctions?

Yes

No

Name and Address:

Application for EMP – continued

Page 3

Do you have childcare privileges?

Yes

No

Name of child(ren):

Address of childcare:

Do you have special family circumstances we should know about?

Yes

No

Explain:

Do you have any disabilities or special medical conditions?

Yes

No

Explain:

Are you currently taking a prescribed medication?

Yes

No

Name of medication(s):

Name of doctors:

Have you ever been treated for drug or alcohol abuse?

Yes

No

Location and reason for treatment?

Do you have regularly scheduled appointments besides work (i.e. treatment, counseling)?

Can you read and write?

Yes

No

Inmate Signature:

Date:

Information verified by:

Correctional Officer

Date

Approved by:

Supervisor

Date