Work Release Intake Form printable pdf download

Dakota County Community Corrections

WORK RELEASE INTAKE FORM

PHONE: 651-438-8258, Option 1; FAX: 651-438-8379;

EMAIL: CCWKRLS@co.dakota.mn.us

ALL FORMS MUST BE SUBMITTED TO WR STAFF BY MAIL, EMAIL, FAX OR

TURNED IN TO THE LEC LOBBY WORK RELEASE BOX AT LEAST 5 BUSINESS

DAYS BEFORE YOUR REPORT DATE!!!

Full Name: _________________________________ DOB: __________________

Court File(s) #: 19-___________________Offense:__________________

Total jail days ordered: __________________ Probation Officer: ________________________

Jail Report Date/Time: _____________________Cell Ph#: (

)_____________________

TREATMENT/SCHOOL:

TRANSPORTATION: (Must be valid

transportation)

Agency: ____________________________

Designated Driver (or self):

_________________________________

Address: ____________________________

Phone: __________________________

City:_________________________________

DL#: _________________________________

Phone: _____________________________

Year/Make/Model/Color of Vehicle:

Counselor/Advisor: ____________________

_______________________________________

Treatment/Class Schedule:

License Plate#: __________________

______________________________

EMPLOYMENT

Company Name: _____________________________________________

Address: ____________________________ City_____________________ Zip Code______________

Supervisor(s): ______________________________________ Phone:___________________________

Job Title: __________________________________Length of Employment: _____________________

Payday: _________________How Often: ___________________ Wage: _______________________

Job Site Location(s) (if different from employer address): ______________________________________

____________________________________________________________________________________

Regular Work Schedule: DAYS: ______________________TIME:____________ to _____________

Supervisor Signature___________________________________________ Date___________________

**PLEASE ATTACH YOUR MOST RECENT PAYCHECK STUB WHEN SUBMITTING**

DAKOTA COUNTY COMMUNITY CORRECTIONS

Work Release Forms

Revised 6/15/2012, 9/11/12, 10/2/12, 12/23/13

Work Release Intake Form