Last Name: ____________________________________________
First Name: ___________________________________ MI: ______
Address: ______________________________________________
County: _______________________________________________
City: __________________________________________________
State: _____________________ Zip Code: ___________________
Phone: (____)______-____________ (____)______-____________
Social Security #: _______________-___________-_____________
Date of Birth: ______________/_______________/_____________
Drivers' License #: _______________________________________
| Race: (circle one) | White Black/African American Hispanic/Latino Asian American Indian/Alaska Native Native Hawaiian/Other Pacific Islander Other |
| Sex: (circle one) | Male / Female |
Degree: _______________________________________________
Major: ________________________________________________
Please complete this form, print and mail to:
Department of Juvenile Justice Central Screening
707 N. 15th St.
Springfield, Illinois 62702
or fax: (217) 557-1107
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