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2. Full Name*

   (First, Middle, Last)

4. Date of Birth*
   Date of Birth
5. Sex (Optional)
   -- Select One --FemaleMale
6. Race (Optional)
8. Other Legal Names
10. Phone Number*
12. Email*
14. Stress Address (Mailing / Local)*
16. City / State / ZIP Code (Mailing / Local)*
18. Street Address (Permanent)
20. City / State / ZIP Code (Permanent)
22. Preferred Means of Communication
    -- Select One --EmailMailPhone

    You may still be contacted by regular mail.

24. Tennessen Warning

    In accordance with Minnesota Statute 13.04, subdivision 2, we must inform you of your rights as a subject of data. The data you have provided above is needed to identify you, contact you, and assist us in determining whether you are eligible to participate in the Winona County Misdemeanor Diversion Program. This data may be distributed to a review panel to determine eligibility. If you are eligible, the information supplied herein will be distributed to the Department of Corrections for purposes of supervision. You are not legally required to provide any of the information we ask you for; however, refusal to supply the requested information may result in your not being appointed to the Council. The questions regarding sex and race are for statistical analysis purposes and may be left blank without consequence. 

26. By my electronic signature:
    • I certify that I am the above-named individual.
    • I certify that I have read and understand the Tennessen Warning outlined regarding my rights as a subject of government data.
    • I authorize the Winona County Misdemeanor Diversion Program to obtain and review my criminal history record information from the Minnesota Bureau of Criminal Apprehension, and to disseminate the information contained therein to a review panel, for the purpose of determining my eligibility. This authorization shall expire one year from the date of signature.
28. Signature*

    Please type your full name.

Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit

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