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2. Winona County Misdemeanor Diversion Program Application

   In accordance with Minnesota Statute 13.04, subd. 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. The 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 ineligibility for the program. The information needed for application processing is marked as required here. The questions regarding gender and race/ethnicity are for statistical analysis purposes and may be left blank without consequence.

4. First Name*
5. Middle Name
6. Last Name*
8. Date of Birth*
9. Gender (optional)
   -- Select One --MaleFemaleOther
10. Race/Ethnicity

    1. American Indian/Alaskan Native
    2. Asian
    3. Black/African American
    4. Hispanic/Latino

    1. Native Hawaiian/Pacific Islander
    2. White/Caucasian
    3. Other
12. Prior Legal Names
14. Phone Number*
15. Email Address*
17. Mailing Address*
19. City*
20. State*
21. Zip Code*
23. Physical Address (if different from mailing address)
25. City
26. State
27. Zip Code
29. Preferred Communication Method (may still receive communication in other formats)

    1. Email

    1. Mail

    1. Phone
31. Signature*

    Please type your full name to indicate that you are requesting your application to participate in the Misdemeanor Diversion Program be reviewed for eligibility.

Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field