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Email*

Legal Name (First, Middle, Last) *

Phone Number (888)-888-8888*

Date of Birth (MM/DD/YYYY)*

Parish of Arrest (i.e. Ouachita, etc)

Name of Arresting Police Department

Date of Arrest (MM/DD/YYYY)

Name of Court (City or Parish)

Outcome of Court Case (Plea, Dismissed, Diversion, Probation, etc)

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