| THE EASTERN CARIBBEAN SUPREME COURT |
| IN THE HIGH COURT OF JUSTICE |
| CASE NO: |
| Length of time in custody so far: |
| Date when you were placed on remand: |
| Surname: Given Names: |
| Alias: Date of Birth: |
| Age: Male Female |
| Name of Parent/Guardian (if under 18) and phone number: |
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| Home address: |
| Nationality: Immigration Status (if non-national): |
| Identification Number (Driver's License, National Identification, or Passport): |
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| Whereabouts of Passport (include name of person who can get it and their phone number): |
| Occupation – type of work: |
| Name of employer and place of work (if any): |
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| Work phone number: |
| Offence(s) for which bail is sought (attach charge sheet if available): |
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| Date(s) of offence(s): |
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| Date(s) when charge(s) laid: |
| Police station and name of arresting officer(s): |
| Name(s) of co-accused (if any): |
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| List of Crimes for which you have been charged at this time: |
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| Have you applied for Bail before and been denied?: Yes No |
| If yes Judge or Magistrate who refused Bail: |
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| Date(s) bail refused: |
| Reasons given for the refusal of bail: |
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| Reasons for this application. Explain: (a) Why the court should grant you bail. |
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| (b) If this is not your first application for bail, what further information or legal argument, if any, has become available since the last bail decision was made. |
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| Date of next Court appearance and where: |
| List all matters for which you were on bail at the time of your arrest: |
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| State whether you have complied with previous bail conditions and if not, why not: |
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| Previous convictions: |
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| Name of possible surety(s): |
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| Address of surety(s): |
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| Telephone number of surety(s): |
| Community ties of surety(s): |
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| The statements in this form of four pages are true to the best of my knowledge and belief and I sign the form knowing that if it is tendered in evidence I shall be liable to prosecution if I have wilfully stated anything I know to be false or do not believe to be true. |
| Applicant's signature or mark if signature not possible: |
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| Date: |
| Before Commissioner for Oaths or Justice of the Peace, Prison Officer, Prison Official or Police Officer (sign and print name and stamp/seal where applicable): |
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