Form 1 - Petition For Certificate Of Rehabilitation And Pardon
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4IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA
IN AND FOR THE COUNTY OF
Applicant's County of Residence
In the Matter of the Application of
Court use only
Type Applicant’s Full Name - First Middle Last and Suffix, if applicable
Date of Birth
Month Day, Year
CII Number
Criminal Case Number(s)
List applicable Criminal Case Number(s)
PETITION FOR CERTIFICATE OF REHABILITATION AND PARDON
Pursuant to Penal Code Sections 4852.01 and 4852.06
The above-named applicant hereby respectfully represents and shows that:
FELONY HISTORY
[
]
All felony convictions must be listed. If you have suffered more than three (3) felony convictions, attach additional sheets following the same format.
Most Recent Felony Conviction
On or about
, I was convicted of the crime of
,
Month Day, Year
Indicate crime and Penal Code Section
in the county of
, California. My sentence for this offense was:
[
]
Check appropriate box
Commitment to state prison or other state institution at
;
Name of institution or city where located
Probation with suspended sentence to state prison or other state institution;
Probation, after the sentencing proceedings were suspended.
Thereafter, on or about
, I was;
Date released from custody
[
]
Check appropriate box
Discharged from state prison or other state institution after completing my sentence;
Released on parole, from which I was finally discharged
;
on
Discharge date
Released from custody on probation after serving a jail sentence;
As a condition of my probation, I was released from custody after serving time in jail, and successfully
completed my probation on
, and obtained relief under Penal Code
Date probation ended
section 1203.4 on
.
Date 1203.4 granted by the Court
FORM 1 (Revised 1/21/98)
This form was prepared by the Investigations Division of the Board of Prison Terms pursuant to Penal Code Section 4852.18.
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