PREVIOUS CRIMINAL RECORD (IF NONE, STATE “NONE” - DO NOT LEAVE BLANK)
Please state ALL offenses for which you have been arrested or charged at any time and in any jurisdiction. You MUST include offenses expunged, juvenile offenses, adjudicated and alcohol related traffic offenses. This section applies even if the charges were dismissed or someone told you the charges would not be on your record. Please use separate sheet for any additional offenses.

I have read the foregoing application. All of the information is true and correct. I understand that if any
of this information is not true and correct, this may be a basis for denial of diversion or revocation of
diversion.

I hereby authorize the County Attorney’s Office to release any information in the County Attorney’s file pertaining to this offense for which I am charged to the Southeast Kansas Mental Health, the Department of Children and Families, and the investigating Law Enforcement Agencies, or any other such person or agencies for use in determining whether I am a suitable candidate for diversion. I further authorize any person, agency or organization to release and provide, upon request, any information to the office of the Bourbon County Attorney in consideration of any application for Diversion.

I further authorize any person, agency or organization that is conducting an evaluation or treatment as part of the diversion application or the diversion agreement to release information to any other person, agency or organization as needed for the evaluation or treatment process.