BMC PFP 09/18 REQUEST FOR MAYORAL Case Number: (the clerk fills this in)

PARDON FOR PROGRESS

In the City of Birmingham Municipal Court }

Name:
First Middle Last

To ask the Mayor of Birmingham to grant a pardon, you must fill out this form, and:
• Attach a copy of your photo ID
• Complete the Request for Pardon for Progress Form
• Submit form to Pardons for Progress - Birmingham City Hall - 710 20th Street North

I declare that the following information is true and correct:

Name:
First Middle Last

Adress:
Street City State Zip

Email Address: Phone Number (cell):

Date of Birth : Date of Conviction (if known):

Last four digits of your SSN:

The attached copy of my government

issued photo ID is my (check one): Driver’s License:

Non-Driver’s Photo ID:

I pray relief from the City of Birmingham, through the Office of Mayor granting of a pardon pursuant
to Code of Alabama, Section 12-14-15, 1975. For the limited purpose of employment (provide details):

I am not now facing criminal charges, nor am I involved in any other court case.
• I have never been convicted of a violent or criminal sex offense (as defined in Code of Alabama,
15-20-21,1975), a crime of moral turpitude, or a felony.
• I do not have a marijuana conviction in any other jurisdiction within the State of Alabama.
• I am not asking for relief to avoid criminal prosecution or to commit fraud.
• I affirm all the information provided above is complete and accurate.

I ask the Mayor of Birmingham to grant this request and to issue an order of relief of the criminal
conviction in the Birmingham Municipal Court.

Signature: Date: