Applicant must type or clearly print all information

Applicant must type or clearly print all information
NAME___________________________________________Date of Birth____________ Last First MI mm/dd/yyyy OLN________________________State______SSN________________Hm Ph #_____________________ Street Address_________________________________City____________Zip_________ Mailing Address_______________________________City____________Zip_________ Commitment Charge_______________________________________________________ Charging Agency___________________Charging Court__________________________ Attorney___________________________________Phone________________________ Physician__________________________________Phone_________________________ Nearest Relative_____________________________Relationship__________________________ Address_____________________________City_____________Phone_______________ Return this application with the following: 1. Employment verification signed by your employer. 2. A copy of your last pay stub. 3. A copy of your drivers license 4. Proof of liability insurance if driving to your place of employment. 5. Copy of bus schedule if using public transportation to commute to work. 6. Name and phone number of driver if another is providing transportation to work. 7. Legible copy of your commitment order authorizing your time to be spent at the Enumclaw City Jail or the facility of defendant’s choice. 8. Copy of any court ordered counseling (AA, NA, Anger Management, ect)
A $25.00 non-refundable fee in the form of cash or money order is to be returned
with this application. Personal/Business checks are not accepted for payment.
EMPLOYMENT INFORMATION
Name________________________________________________________________ Address__________________________________________City_________________ Phone_______________________Occupation_______________________________ Name_________________________________Phone__________________________ Jobsite if different than company address listed above_________________________ Length of employment_________________________Wage per hour $____________ Is employer related to you?______________If yes, how?_______________________ Pay periods___________________________Method__________________________ (Weekly-biweekly-monthly) (Cash-check-direct deposit) WORK SCHEDULE
START TIME
TRANSPORTATION
Do you have a valid drivers license?_______________________State____________ What is your drivers license status?(Clear/Revoked/Suspended)__________________ How do you commute to work?___________________________________________ How long is your commute to work from the work release facility?_______________ How long is your commute from work to the work release facility?_______________ If you commute to work by bus, what are the bus/route number(s) & time caught to work from the work release facility?_______________________________________ If you return to the work release facility by bus, what are the bus/route numbers & times________________________________________________________________ Do you have current/valid liability insurance on your vehicle?___________________ What is the name of your insurance company?_______________________________ What is your insurance policy number?_____________________________________ What is the name of your insurance agent?__________________________________ What is your insurance agent’s contact number?______________________________ What illegal drugs have your tried?________________________________________ What illegal drugs do you currently use?____________________________________ How often do you use alcohol & in what amount?_____________________________ List any medications you are currently taking: Do you have any allergies?_______________________________________________ History or seizures disorders?_____________________________________________ Mental Health problems?________________________________________________ ARREST HISTORY
**Include ALL arrests: Felony, Misdemeanor and Traffic** If more room is needed Have you ever been rejected or removed from any work release or home detention List any other work release or electronic home detention facilities you have served Are you on currently on probation or parole? Probation/Parole Officer name & phone _________________________________ __________________________________________________________________ Have you EVER been on probation or parole? Have you ever been removed from probation/parole for disciplinary reasons? AA/NA MEETINGS
You must provide written verification on any counseling dates when you return this CHARGES/COURT ACTION PENDING
Are there any Restraining Orders/No Contact Orders against you? Yes___No___ If yes, list the name, address and phone number of the person(s) on the order _____________________________________________________________________ _____________________________________________________________________ WORK RELEASE INFORMATION SHEET
Participant acknowledges by his signature that participation in the Work Release Program has been voluntarily entered into, and that this document has been fully explained to the participant, and that he understands and agrees to abide by all the rules and regulations of the Work Release Program. Participation costs shall be paid at the rate of $60.00 per day including weekends. Participant agrees to pay in the form of cash or money order. All fees shall be paid in full at the time of booking.
PARTICIPANT REQUIREMENTS
The participant agrees to ALL the following terms and conditions:
1. To obey all terms and conditions of the Work Release Program. To perform all tasks and be present at the times specified, in a manner satisfactory to the Jail 2. To abstain from the use of alcoholic beverages during participation in the Work Release Program. ANY COMSUMPTION WILL CAUSE YOUR
REVOCATION FROM THE WORK RELEASE PROGRAM.
3. To submit to a breath test and provide breath samples at any time as requested by a corrections officer. . FAILURE TO SUBMIT TO SUCH TEST OR
REFUSAL TO PROVIDED SUCH SAMPLE SHALL BE DEEMED
SUFFICIENT GROUNDS TO TERMINATE YOU FROM THE WORK
RELEASE PROGRAM
4. To abstain from the use of all drugs except those prescribed to you by a licensed 5. To obey all federal, state, county and local laws. 6. To provide a urine sample, under observation, and at any time, as requested by a corrections officer. FAILURE TO SUBMIT TO SUCH TEST OR REFUSAL
TO PROVIDE SUCH SAMPLE SHALL BE DEEMED SUFFICIENT
GROUNDS TO TERMINATE YOU FROM THE WORK RELEASE
PROGRAM.
7. To not drive or operate any motor vehicle, which requires a license, without proper proof of a valid drivers license, proof or liability insurance and possible 8. To proceed to and from your place of employment/worksite by the most direct route, without deviations or stops of any kind not previously approved by the Jail Sergeant. A delay of more than thirty (30) minutes in your return will cause corrections staff to attempt to verify your location. Any longer delay or repeated delays, without cause, may be reason to revoke you from the Work Release • Car problems • Natural disaster • Life threatening medical emergencies • Unforeseen traffic delays 9. To not bring any item(s) or contraband into the facility or remove any item(s) 10. To keep your person and living quarters clean and neat. 11. To follow all directions given by corrections officers. 12. The Enumclaw City Jail is a non-smoking, tobacco free facility. 13. Personal mail cannot be delivered to the jail. You are responsible to make 14. Participants may not work more than 48 hours per week, unless pre-approved by the Jail Sergeant. Participants must spend at least two (2) full days in the facility per week unless otherwise directed by court order or the Jail Sergeant. 15. Participants agree to assume full responsibility for all items brought into the facility. All items must be pre-approved by the corrections staff. 16. Participants understand that the Chief of Police or his designee may discontinue REVOCATION OF WORK RELEASE
Participants agree and acknowledge that violation of any of the above requirements, or refusal to submit to any requested/required test, may result in their removal from the Work Release Program and/or conversion of any remaining sentence to straight
time incarceration.
If you would like to be notified by email of the status of your application please _________________________________________________

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