Please fill out all fields you can. Any missing information may result in a delay in processing or denial. All information is confidential and will only be utilized for law enforcement and jail facility purposes. If you have difficulty with this form you can download a PDF version of the application with all additional materials and return them in person.

In order for this application to be processed a non-refundable $100.00 cash fee must be paid in person at the Fullerton Police Department, 237 W. Commonwealth, Fullerton, CA 92832.

Last Name Required
First Name Required
Middle Name
You must be at least 18 years of age to serve your sentence at Fullerton Jail.
Date of Birth Required
Driver's License State
Address Required
  City State Zip
Home Phone
Work Phone
Cell Phone
Email
Emergency Contact Name
  Phone Number

Medical Information

Do you have any of the following medical problems? If yes, check symptoms on list.




Type of Inhaler Frequency
Are you currently under the care of a doctor for medical or psychiatric reasons?
Are you taking or do you need to take any prescribed medications?
Have you had a recent head injury in the last 72-hours?
Have you ever attempted suicide? When? Method?
Are you thinking about suicide now?
Who is your medical insurance carrier?
Policy Number Contact Number

Sentencing

Under what Court authorized sentencing structure will you be completing your sentence
Court Case Number Required
Court of Jurisdiction Required
Charges Convicted Of Required
Fullerton Jail can only accept sentences that are 364 days or less in length.
Length of Sentence Days Required
When do you need to begin serving your sentence? Required
By what date do you need to complete this sentence? Required

Attorney of Record

Attorney Name
Attorney Phone Number
Address
  City State Zip

Employment Information

Are you employed?

School Information

Are you a student?

Agreement


I agree to follow the rules and regulations of the City of Fullerton Police Department Trustee program at all times. I understand that failure to obey all rules or inability to pay all required fees will result in termination of participation in the program. Termination of participation in the program will result in my being remanded into the custody of the Orange County Sheriff to complete the remainder of my sentence. It is further understood that removal from the program may result in the loss of any and all good time/work time accrued.

Valid characters generally include: letters, numbers and: period (.), dash (-), apostrophe (').

Contact Fullerton PD Jail, 714.738-6722, if you have problems with this form.