REQUEST TO RESTRICT AND SEAL RECORD

Please select a date and time for your appointment and fill in the registration form

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April 2024

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First Name *

Last Name *

Middle Name

Maiden Name

Date of Birth *

Race *

Sex *

Phone *

Email *

Street Address *

City *

State *

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What is the best way to reach you?

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Are you currently on probation or parole in any county (misdemeanor, felony, or non-reporting)? If yes, please enter any additonal information

Yes No

Do you have a pending criminal case in any jurisdiction? If yes, please enter any additional information

Yes No

Have you ever been arrested outside of the state of Georgia? If yes, Please enter City, County, State of your arrest

Yes No

I hereby give my consent for the Cobb County Second Chance Desk Partners (Cobb County Circuit Defender, the Office of the Solicitor General of Cobb County, or the Cobb County District Attorney’s Office) to retrieve my Georgia Crime Information Center (GCIC) criminal history under purpose code U for purposes of reviewing my record to determine restriction (restriction and sealing) eligibility. I understand that my GCIC criminal history will be shared with the Georgia Justice Project (a non-profit law firm) for review and consultation at the Cobb County Second Chance Desk.
This authorization is valid for 365 days.

Limited Scope Representation – Georgia justice Project (GJP), a non-profit organization, will be my attorney for purposes of receiving and reviewing my GCIC criminal history report in preparation for my appointment at the Cobb Second Chance Desk. GJP will not disseminate or share my GCIC report beyond staff or volunteers assisting with the Cobb Second Chance Desk without my permission. GJP will not become my attorney for any other purpose absent a fully signed representation agreement between me and the Georgia Justice Project.

Signature

Date

Notes for Applicant - If you have any of the following documents, please bring them to your appointment:

Case documents for charges you want expunged
Case documents for other charges on your record
Job or housing denials due to your record
Denials or communications from occupational licensing boards
Prior requests to clean up your record