Enrollee Information Request Please use proper capitalization in filling out this application. This form is ONLY for potential offenders that need help with their home incarceration needs. IMPORTANT: If the person needing our service is currently incarcerated we are unable to help them at this time. They will have to seek approval from the court to convert their sentence to home incarceration. Once this has been done, then they can reach out to us for further assistance. Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email* Landline or Mobile Phone?*LandlineMobileLandline Phone NumberMobile Phone NumberDo you authorize us to contact you via text message if necessary?* YES NO How did you hear about us?*SelectAttorneyBingCourt ReferralFamily MemberFriendGoogleOtherParole OfficerProbation OfficerYahooWere you arrested in the same county you live in?* YES NO What is the name of the Court?*What state is the court in?*Do you have a court date?* YES NO What is your court date?* Please explain.*Attorney's Name*Law Firm Name*Attorney's Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Privacy StatementAll information you enter is protected and will never be shared.