APPLICATION FOR CLEMENCY Check box for type of clemency desired. All applications must have the proper court documents attached. O Restoration of Civil Rights for Florida conviction O Specific Authority to Own, Possess or Use Firearms (Eligible 8 years after completion of sentence) O Restoration of Civil Rights in Florida for Federal, O Full Pardon (Eligible 10 years after completion of sentence) Military, or Out-of-State conviction O Restoration of Alien Status Under Florida Law O Remission of Fine or Forfeiture O Pardon Without Firearm Authority (Eligible le years after completion of sentence) Commutation of Sentence (Use Form "Request for Review") If you have applied for a Full Pardon, Pardon Without Firearm Authority or Specific Authority to Own, Possess or Use Firearms and are determined ineligible due to not meeting the time requirement, you will be processed for Restoration of Civil Rights. If you have already received Restoration of Civil Rights, a Certificate for Restoration of Civil Rights will be mailed to you. Your signature acknowledges you understand this action. SIGNATURE Name When Convicted: Current Name: Date of Birth: PLEASE PRINT Other Names Used: Race: Sex: O Male ❑ Female Driver License #: U.S. Citizen? OYes O No - Alien Registration Home Address: Social Security #: Street City County State Zip Mailing Address: Street City County State Zip Home Telephone #: Cellular Telephone #: E-mail Address: PRISON/PROBATION #: CONVICTIONS: (Please list each conviction and provide court documents for each conviction. If you have more than two convictions, please attach a separate sheet of paper listing all the required information.) YOU DO NOT NEED TO FILL OUT A SEPARATE APPLICATION FOR EACH CONVICTION. Court County/State Date Convicted Date Sentenced What was your sentence? Date you completed/expired your sentence: (Please Circle one of the following: Prison Jail Release Parole Probation) Signature Date YOU DO NOT HAVE TO HAVE AN ATTORNEY FOR THIS PROCESS. Do not list the attorney who represented you during the criminal proceedings. If you have chosen to be represented by an attorney for the clemency process, please provide the Attorney Name, Address & Telephone Number. Attorney Name Address Telephone Number Attach a certified copy of the following for EACH felony conviction: charging indIctmenUlnformation; judgment; and sentence/community control/probation order. APPLICATIONS SUBMITTED WITHOUT THE PROPER COURT DOCUMENTS WILL NOT BE ACCEPTED. This application form and Rules of Executive Clemency are available on the Internet at: lutps://fpc.state.fLus/Clemency.htm Mailing Address: Office of Executive Clemency 4070 Esplanade Way Tallahassee, FL 32399-2450 Fonn ADM 1501 Updated 04/24/2012-Mc EFTA01092484