Application to Seal Record – Fairfield County Juvenile Division

Name Date of birth Age Address City State ZIP code Phone number Social Security Number Drivers license

Type of case

Delinquency Traffic

Were you on probation or parole as a result of this charge

Yes No

Name of probation or parole officer

Have you been adjudicated or convicted of any juvenile or adult criminal or traffic offenses since your last contact with the court

Yes No

Previous offense row 1 date Previous offense row 1 offense Previous offense row 1 court or location Previous offense row 2 date Previous offense row 2 offense Previous offense row 2 court or location Previous offense row 3 date Previous offense row 3 offense Previous offense row 3 court or location

Is your drivers license currently suspended

Yes No

Are you going to school

Yes No

Have you been suspended from school since your conviction

Yes No

If so, for what If so, where What are your grades

Are you employed

Yes No

If so where How long Employment history row 1 date Employment history row 1 location Employment history row 1 reason for leaving Employment history row 2 date Employment history row 2 location Employment history row 2 reason for leaving Employment history row 3 date Employment history row 3 location Employment history row 3 reason for leaving Other activities row 1 date Other activities row 1 organization Other activities row 1 activity Other activities row 2 date Other activities row 2 organization Other activities row 2 activity

Please indicate any other information you would like the Court to know in reviewing your application. You may attach separate sheets if necessary. Signature of applicant Date signed by applicant Signature of parent or guardian Date signed by parent or guardian