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STATE OF NEW YORK
FOR COURT OR BOARD OF PAROLE
Docket, File or other Identifier
APPLICATION BY AN ELIGIBLE OFFENDER FOR
Form Instructions
CERTIFICATE OF RELIEF FROM DISABILITIES
1.
Applicant's Last Name
First Name
Initial
3.
NYSID (if known)
2.
Address (Street and House Number, City, State, ZIP)
4.
Sex
5.
Race
6.
Height
7.
Date of Birth (Month/Day/Year)
M ale
Female
Ft
In.
8.
Offense for which convicted
9.
Date of arrest
10. Date of sentence
11. Court of Disposition (Court, Part, Term, Venue)
12. Certificate issued by:
Court indicated in box 11
State Board of Parole
13.
Certificate is intended to replace an existing certificate,
issued on:
Not applicable
14. Application is hereby made for a grant of a Certificate of Relief from Disabilities which will
a.
relieve the holder of all forfeitures, and of all disabilities and bars to employm ent, excluding the right to retain
or to be eligible for public office, by virtue of the fact that the certificate is issued at the time of sentence.
b.
relieve the holder of all disabilities and bars to employment, excluding the right to be eligible for public office.
c.
relieve the holder of the forfeitures, disabilities or bars to employment hereinafter enumerated
15. The applicant agrees to allow an investigation to be made to determine his or her fitness for a certificate of relief
from disabilities, pursuant to Correction Law Article 23.
Applicant’s Signature
Date
sign in the presence of a notary
16.
State of New York )
ss.:
County of _________ )
____________________________________, being duly sworn, deposes and says that __he is the applicant named in
the within application; that __he has read the foregoing application and knows the contents thereof; that the same
his
is true to h____ own knowledge, except as to the matters therein stated to be alleged on information and belief,
and that as to those matters __he believes it to be true.
Sworn to before me this _____ day of _____________ 20___
_________________________________
Notary Public
affix stamp / seal
DC- DPCA-52 (6-05)