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Community Service Form

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Steps

1. Step One This section is complete This section is incomplete
2. COMMUNITY SERVICE FORM This section is complete This section is incomplete
3. EMPLOYER INFORMATION This section is complete This section is incomplete
4. EMERGENCY CONTACTS This section is complete This section is incomplete
5. COURT INFORMATION This section is complete This section is incomplete

Step One

Disclaimer
Information submitted on this form will be sent using email. Please do not include social security numbers, Drivers License numbers, or any other personal information other than the requested information on the form.
I have paid my fees online or in person before filling out this form?*
1. YES
1. NO
Continue

COMMUNITY SERVICE FORM

Last Name*
First Name*
Middle
Date of Birth*
Date of Birth
mm/dd/yyyy
Email Address*
Where we may contact you
Phone Number*
Where we may contact you
Address*
Include Apt # if applicable
City*
State*
Zip Code*
Hair Color:*
Eye Color*
Height
In Feet and Inches
Weight
In pounds (lbs.)
Gender*
Race*
Marital Status
US Citizen?
1. YES
2. NO
Veteran?
1. YES
2. NO
Current Student?
1. YES
2. NO
Level of Education Completed
Driver's License?
1. YES
2. NO
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EMPLOYER INFORMATION

Employer
Employer Phone #
Include Area Code
Address
City
State
Zip Code
Weekly Hours
Hourly Wage in Dollars
Disabled?
1. YES
2. NO
Monthly Income in Dollars
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EMERGENCY CONTACTS

First Name*
Last Name*
Relationship*
Phone Number*
Address*
Include Apt# if Applicable
City*
State*
Zip
First Name
Last Name
Relationship
Phone Number
Address
Include Apt# if applicable
City
State
Zip
Continue |Go Back

COURT INFORMATION

Case/Cause Number
Date
Date
First Name
Last Name

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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20 North Third Street
Lafayette, IN 47901
Phone: 765-423-9215

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