Suffix
Any other name that might be used on your record ?
Date Of Birth
Race
Gender
Social Security Number
Phone Email
Address
City State
Zip Code
Arresting Agency
Date of Arrest
Driver’s License Number State Identification Number
Issuing state
Case Number
Offense(s) Arrested For
You will receive an email to the email address provided once your application is received. The District Attorney's Office will contact you once your application is processed or if additional information is needed.
Please ensure all information above is correctbefore submitting form.
Confirm Your Restricton Form
Date of Arrest:
Charge:
Arresting Agency:
Confirm Your Address
First Name:
Last Name:
Address:
City/State/Zip:
Phone Number:
Payment
Card Information
Your application has been successfully submitted
We wil now consider your ENTIRE record for possible restricton
You do not need to resubmit the application if you have additional charges.
Thank you in advance for your patience
Please expact further communication in the method that you selected in the application form
