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Currently Recieving any Social assistance?
Select an answer please
No
Yes
Current/Seeking Employment In Cannabis Industry?
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No
Yes
Are you Currently Incarcerated?
Select an answer please
No
Yes
Charges:
<div class="row"><div class="col-md-4 form-group no-side-margins text-right"><label>1. Date of Arrest</label></div><div class="col-md-6"><div class="form-group no-side-margins"><input type="text" name="patient_medical_info[arrests][0][date_of_arrest]" id="patient_medical_info_arrests_0_date_of_arrest" data-inputmask="&#39;mask&#39; : &#39;99/99/9999&#39;" label="false" class="form-control" /></div></div></div><div class="row"><div class="col-md-4 form-group no-side-margins text-right"><label>2. Age at Time of Arrest</label></div><div class="col-md-6"><div class="form-group no-side-margins"><input type="text" name="patient_medical_info[arrests][0][age]" id="patient_medical_info_arrests_0_age" label="false" class="form-control" /></div></div></div><div class="row"><div class="col-md-4 form-group no-side-margins text-right"><label>3. Municipality</label></div><div class="col-md-6"><div class="form-group no-side-margins"><input type="text" name="patient_medical_info[arrests][0][municipality]" id="patient_medical_info_arrests_0_municipality" label="false" class="form-control" /></div></div></div><div class="row"><div class="col-md-4 form-group no-side-margins text-right"><label>4. What were you charged with?</label></div><div class="col-md-6"><div class="form-group no-side-margins"><input type="text" name="patient_medical_info[arrests][0][what_charged]" id="patient_medical_info_arrests_0_what_charged" label="false" class="form-control" /></div></div></div><div class="row"><div class="col-md-4 form-group no-side-margins text-right"><label>5. Were you found guilty?</label></div><div class="col-md-6"><div class="form-group no-side-margins"><select name="patient_medical_info[arrests][0][guilty]" id="patient_medical_info_arrests_0_guilty" label="false" class="form-control"><option value="">Select an answer please</option><option value="false">No</option> <option value="true">Yes</option></select></div></div></div><div class="row"><div class="col-md-4 form-group no-side-margins text-right"><label>6. Relevant File Number</label></div><div class="col-md-6"><div class="form-group no-side-margins"><input type="text" name="patient_medical_info[arrests][0][file_number]" id="patient_medical_info_arrests_0_file_number" label="false" class="form-control" /></div></div></div><div class="row"><div class="col-md-4 form-group no-side-margins text-right"><label>7. Was the Charge Dismissed?</label></div><div class="col-md-6"><div class="form-group no-side-margins"><select name="patient_medical_info[arrests][0][charge_dismissed]" id="patient_medical_info_arrests_0_charge_dismissed" label="false" class="form-control"><option value="">Select an answer please</option><option value="false">No</option> <option value="true">Yes</option></select></div></div></div><div class="row border-bottom m-b-xs"><div class="col-md-4 form-group no-side-margins text-right"><label>8. Are you Currently Incarcerated for this charge?</label></div><div class="col-md-6"><div class="form-group no-side-margins"><select name="patient_medical_info[arrests][0][currently_charged]" id="patient_medical_info_arrests_0_currently_charged" label="false" class="form-control"><option value="">Select an answer please</option><option value="false">No</option> <option value="true">Yes</option></select></div></div></div>
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Were you ever convicted of any of the following Crimes?
Murder
Rape
Robbery
Aggravated Sexual Assault
Endangering the Welfare of a child
Manslaughter
Forced Sodomy
Embracery
Criminal Sexual Contact
1st or 2nd Degree Drug Charges
Treason
Arson
Death by Auto
Criminal Restraint
Anarchy
Perjury
Luring Enticing
Kidnapping
False Swearing
Have you ever had any criminal offense expunged?
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No
Yes
Is there any current pending litigation against you?
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No
Yes
List your closest living relatives and their relation to you:
How has having this conviction impacted your life?
Notes Section:
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