Charge: Date: Law Enforcement Agency involved: Disposition: Charge: Date: Law Enforcement Agency involved: Disposition: Have you ever been convicted of any domestic violence related offense? Yes No If yes, explain: Have you ever tried or used marijuana? Yes No If yes, how many times? When was the first time? When was the last time? Have you ever sold, delivered, and/or stored any illegal drugs? Yes No If yes, explain: VI. CRIMINAL ACTIVITY (CONTINUED) Have you ever used or experimented with any illegal drugs other than marijuana? (PCP, THC, LSD, Mushrooms, Heroin, Cocaine, Crack, Qualuudes, Opium, Uppers, Downers, STP, Meth, Others)? Yes No If yes, complete below: Drug: Number of times used: First time used: Last time used: Drug: Number of times used:
Charge: Date: Law Enforcement Agency involved: Disposition: Charge: Date: Law Enforcement Agency involved: Disposition: Have you ever been convicted of any domestic violence related offense? Yes No If yes, explain: Have you ever tried or used marijuana? Yes No If yes, how many times? When was the first time? When was the last time? Have you ever sold, delivered, and/or stored any illegal drugs? Yes No If yes, explain: VI. CRIMINAL ACTIVITY (CONTINUED) Have you ever used or experimented with any illegal drugs other than marijuana? (PCP, THC, LSD, Mushrooms, Heroin, Cocaine, Crack, Qualuudes, Opium, Uppers, Downers, STP, Meth, Others)? Yes No If yes, complete below: Drug: Number of times used: First time used: Last time used: Drug: Number of times used:
wcsoapplication.docx