CLETS FormCal. Super. - 6th Dist.May 3, 2021SUPERIOR COURT 0F CALIFORNIA COUNTY OF SANTA CLARA CLETS BACKGROUND INFORMATION FORM NAME CHANGE ”2%3’Mmoa 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: Nguyen A1111 Mai LIST ANY OTHER NAMES THAT YOU USE, INCLUDING MAIDEN NAME, BIRTH NAME 0R NICKNAMES: 1. 2. 3. RESIDENCE: STREET ADDRESS CITYJSTATE ZIP PHONE NUMBER: 1350 Oakland Road, SPC 59 San Jose, CA 95112 (408) 444-0888 MAILING ADDRESS IF DIFFERENT FROM RESIDENCE: BUSINESS PHONE: DATE 0F BIRTH: AGE: PLACE OF BIRTH: SEX: HEIGHT: WEIGHT: HAIR: EYES: (STATE 0R COUNTRY) 11/10/2000 20 Vietnam F 5 0 100 lbs Brown Brown DRIVER LICENSE N0.: STATE: EXPIRATION DATE: SOCIAL SECURITY N0.: U.S. CITIZEN: Y4006148 ‘ CA 11/10/2025 220 - 65 -4018 YES No D SCARS, MARKS 0R TATTOOS: IF YES, DESCRIBE. Q I certify the aboveinformatw Signature Date: 04/26/2021M\ / \3 FOR COURT USE ONLY: 3 8 1 1 8 4 DATE SENT To SHERIFF: CASE NUMBER: 2 1 C V DATE DUE BACK To SUPERIOR COURT: DATE 0F APPLICATION: MAY fl 3 ZEN HEARING DATE: f/é/oz 00H P344310 REV 4103 CLETS BACKGROUND INFORMATION FORM Page 1 on (CCP 1279.5 - Name Change)