Chattanooga Endeavors :: New Jobs - New Skills

* Must use INTERNET EXPLORER to Generate PDF after Submission
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Referring Agency & Official

* Denotes Required Field


* Referring Agency
	TN Board of Probation & Parole	* First Name:
	TN Department of Corrections	* Last Name:
	HAM CO. Community Corrections	* Title:
	US Probation	* Email:
	Other
	If other, please list here

	I am or will be supervising this individual in the community.
	YES
	NO

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Candidate Information

* Prefix:

* First Name:

* Last Name:

* Birth Date:

Prison Number:

Institution:

* Current Address:

* City:

* State:

* Zip:

This is a prison address?

Home Phone:

if available

Anticipated or Actual:

if applicable

* Current Conviction/s:

Please confirm that client your meets each of the following eligibility criterion:

Has been convicted of a felony

Does not have any outstanding warrants

Is or will be a resident of the Hamilton County area

Was or will be released from prison (or sentenced to probation) within 12 months

Never convicted of a sexual crime

Not suffering from an untreated mental illness

Is or will be ready, willing and available to work in Hamilton County

Has not, to my knowledge, used any illegal or unperscribed drugs in the last 60 days.

Special Conditions if applicable

Other Comments

I attest that the information provided is, to the best of my knowledge, true and correct.

CEi does not discriminate on the basis of race, color, religion, gender,
national origin, age, or any other characteristic protected by law.

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