Ninth Judicial Circuit AEP Application

Last Name

First

Middle

JR/III

SSN

Cell

Street/P.O. Box

Apt#

City

State ---Select--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Maiden Name/NickNames

Race/Sex

Birthdate

State where you were born

Driver's License#

State where license was issued ---Select--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Your personal Email Address

Please list where you have lived for the last 2 years

Are you a US Citizen?

Yes

No

Are you Military, Active or Reserves?

Are you a US Veteran?

Yes

No

If YES, approximate date of discharge. Include Date/Month/Year

Do you have an attorney for the AEP Charge(s)? Attorney Name:

(A Defense Attorney is not required to make application to AEP)

Please check each space that applies to you:

Married

Widowed

Divorced

Separated

Never Married

Cohabitating

Full time student

Part time student

Not a student

Employed Fulltime

Parttime

Unemployed

Disabled

Retired

Personal income:

0-5,000

5-10,000

10-20,000

20-30,000

30-40,000

40-50,000

Over 50,000

Household income:

0-5,000

5-10,000

10-20,000

20-30,000

30-40,000

40-50,000

Over 50,000

Total number of years of school completed (ex: High School = 12, College = 2, etc)

Name of College, Technical or High School now attending

Are you currently employed?

Yes

No

Job Title

Name of employer

For how long?

List you places of employment for the last two years

Have you ever applied or been in any (PTI) pretrial intervention program before?

What criminal charge(s) are being referred to AEP?

I received this charge in (if not sure please call the office at 843-958-1902)

Charleston County

Berkeley County

Are there any other criminal charges pending against you at this time in any other court? If so describe.

Were there any other charges that occurred at the same time that have not been sent to AEP?

If so, what has happened with the charge(s)?

Dismissed

Paid Fine

Convicted

Not Sure

In your own words, describe how this incident occurred?

Have you ever been on SUPERVISED PROBATION for any criminal charge or citation?

Yes

No

Were there any guns involved in this arrest (other than police officers weapons)

Yes

No

Is your family aware of your AEP arrest

Yes

No

Were you detained one or more nights at the jail on this charge

Yes

No

If YES - how many

Did you pay a bond on this charge?

Yes

No

if yes, to who?

The Court

A Bonding Agency

Have you ever been arrested or given a criminal citation, before the charge you are being referred to AEP on?

Yes

No

If you answered "YES", list any criminal citations or arrests since the age of 17.

What was the outcome of the charges you report?
Do not include minor traffic violations: Please note: DUS is Driving Under Suspension and DUI is Driving Under the Influence, these are criminal offenses. Example; DUI-2years ago-paid a fine.

The following information will be used to identify intervention needs.

Who lives in your home with you? (List their relationship with you and their ages)

Were you the primary care giver for the children in your home at the time of arrest?

Yes

No

Describe your general health

Good

Fair

Serious Concerns

Is your financial situation

Stable

Fair

Serious Concerns

Is your family situation

Good

Fair

Serious Concerns

What do you hope to gain from this program?

MY INFORMATION I HAVE GIVEN IS CORRECT AND TRUE. I HAVE NO OTHER CRIMINAL HISTORY OTHER THAN WHAT I HAVE LISTED AND I UNDERSTAND THAT I MAY HAVE NO NEW CRIMINAL CHARGES FROM THIS DAY FORWARD. IF I HAVE AN ADDITIONAL CRIMINAL CHARGE WHILE ON AEP I WILL BE UNSUCCESSFULLY TERMINATED.

I ALSO UNDERSTAND I MAY USE NO ILLEGAL SUBSTANCES OR PRESCRIPTIONS NOT PRESCRIBED BY A DOCTOR TO ME. IF UNDERAGE, I MAY NOT DRINK OR POSSESS ALCOHOL. IF I AM IN AEP MY ALCOHOL USE MAY BE PROHIBITED.

IMPORTANT: NO APPLICATION CAN BE FINALIZED WITHOUT ALL ITEMS BELOW SENT TO THE AEP OFFICE WITHIN 10 BUSINESS DAYS.

1. Copy of your recent picture ID
2. Copy of your Social Security Card

I UNDERSTAND ALL FEES PAID TO THIS PROGRAM ARE NON-REFUNDABLE. APPLYING FOR AEP IS NOT A GUARANTEE OF ELIGIBILITY. A BACKGROUND CHECK WILL BE COMPLETED PRIOR TO ACCEPTANCE/ PARTICIPATION.

BY CHECKING THIS BOX, I CERTIFY THAT THIS IS MY APPLICATION AND I AGREE TO THE TERMS ABOVE.