SUPERIOR COURT OF NEW JERSEY
CRIMINAL DIVISION
APPLICATION TO THE DRUG COURT PROGRAM
Revised 04/2006, CN: 10753-English page 1 of 1
Vicinage Date of Application
Name Alias
Address Telephone #
City State Zip
How Long at This Address Citizenship Status
Co-Habitant Relationship
Previous Address
Emergency Contact Relationship Telephone #
Defense Attorney Telephone #
Current Charges Indictment #
P/G #
Next Court Event Date Judge
Date of Arrest Location of Arrest
Employer Telephone #
Employer’s Address
Race Sex DOB Social Security #
SBI # FBI # Height Weight
Driver’s License Eye Color Hair Color
Distinguishing Marks
Presently Incarcerated? No Yes Jail #
Detainers? No Yes Jurisdiction(s)
On Probation? No Yes Parole? No Yes PO’s Name
Signature of Defendant Signature of Defense Attorney
