CLETS Background Information Form {PB-4010}

SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CLARA CLETS BACKGROUND INFORMATION FORM Pursuant to CCP 1279.5, the court is required to conduct a background investigation to determine whether an applicant for a name change is under the jurisdiction of the California Department of Corrections or is required to register as a sex offender (PC 290). To conduct this investigation, the following form must be completed. In the process of completing this form, please print your information. If any section does not apply to you, please indicate "DNA". LAST NAME: FIRST NAME: MIDDLE NAME: LIST ANY OTHER NAMES THAT YOU USE, INCLUDING MAIDEN NAME, BIRTH NAME OR NICKNAMES: 1. 2. 3. RESIDENCE: STREET ADDRESS CITY/STATE ZIP PHONE NUMBER: MAILING ADDRESS IF DIFFERENT FROM RESIDENCE: BUSINESS PHONE: DATE OF BIRTH: AGE: PLACE OF BIRTH: (STATE OR COUNTRY) SEX: HEIGHT: WEIGHT: HAIR: EYES: DRIVER LICENSE NO.: STATE EXPIRATION DATE: SOCIAL SECURITY NO.: U.S. CITIZEN: YES SCARS, MARKS OR TATOOS: IF YES, DESCRIBE. NO I certify the above information is correct. Signature Date: FOR COURT USE ONLY: CASE NUMBER: _____________________________________ DATE OF APPLICATION: ______________________________ DATE SENT TO SHERIFF: _____________________________ DATE DUE BACK TO SUPERIOR COURT: ________________ HEARING DATE: _____________________________________ PB-4010 REV 4/03 CLETS BACKGROUND INFORMATION FORM (CCP 1279.5 ­ Name Change) Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com