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Jail Pay to Stay Program
Apply Here
Apply Here


BEVERLY HILLS POLICE DEPARTMENT
JAIL BUREAU
PAY TO STAY - PROGRAM APPLICATION

Instructions: Please provide ALL information requested. If the question is not applicable, indicate N/A. Any informational item not completed may result in a delay in processing the application or a denial. All information is confidential and will only be utilized for law enforcement and jail facility purposes.

In order for this application to be processed a money order or cashiers check for $25 must be sent to: Pay to Stay Program - Beverly Hills Police Jail, 464 N. Rexford Drive, Beverly Hills, CA 90210.

Applicant Name (Last, First M.I.)
Alias(es):
Residence Address:
Date of Birth: Sex:
Race: SSN:
Driver's License Number: Issuing State:
Res Phone: Work Phone:
Cell Phone: Fax:
Email Address:


Emergency Contact Information
Contact Name
(Last, First M.I.):		 Relationship:
Contact Phone 1: Contact Phone 2:


B. Jail Commitment Information

In addition to completing the information below, you will need to submit a certified copy of the Court Commitment or Minute Order with this application.

Under what Court authorized sentencing structure will you be completing your sentence (select one): Straight Time Week-ends Work Furlough
Court Case Number:
Court of Jurisdiction:
Charge(s) Convicted of:
Length of Sentence:
By what date do you need to complete this sentence?
When do you need to begin serving your sentence?
Name, address and phone number of your Attorney of Record in this case:


C. Employment Information
Occupation:
Employment Status: Self Employed Unemployed Student
Name/Address of Employer:
Name of Supervisor: Supervisor’s Phone Number:
Name/Address of School:
Name of Advisor or Contact: Advisor/Contact Phone Number:


D. Medical Questionnaire

All information provided herein is strictly confidential. This information is necessary to ascertain eligibility for this program, as the health and welfare of ALL inmates is critical to the safe operation of the Jail facility. The Beverly Hills Police Department Jail Facility does NOT have a trained medical staff on-site. Be advised that those applicants accepted into this program will be housed in private cells, but will be sharing common areas such as the dayroom, cell block area and a shower facility, with other Pay to Stay Program inmates.

Do you have any of the following medical conditions?
Allergies Fracture/Sprain AIDS/HIV
Asthma: Type of Inhaler Heart Condition Hepatitis
Dental condition Hypertension Herpes
Diabetes Hyperglycemia Tuberculosis
Epilepsy Hypoglycemia Venereal disease
Fainting Spells: Seizures: Type and Frequency Other:
Have you had any major surgery? No Yes If Yes, please provide explanation and how long ago:
Have you ever been admitted to a Psychiatric Hospital? No Yes If Yes, please explain:

Are you currently under the care of a doctor for any medical or psychiatric reasons?

 No Yes If Yes, please explain
Have you had any head injuries in the last 60 days? No Yes If Yes, please explain

Have you travelled outside the Continental United States in the last 90 days?

 No Yes If Yes, where?
Have you ever attempted suicide? No Yes If Yes, please explain:

Are you thinking of suicide?

 No Yes If Yes, please explain:

Are you taking or need to take any prescription medication?

 No Yes If Yes, please provide type and frequency:

NOTE: A medical clearance from a physician is required to verify that you have no health related issues that would prevent the successful completion of your court order sentence

I hereby certify under penalty of perjury that my responses provided herein are true and correct. I understand that any misstatement of facts and/or false statements will disqualify me from the Beverly Hills Jail Facility "Pay to Stay" program. If I am accepted into the "Pay to Stay" program, I agree, on behalf of myself, my heirs, executors and assigns, to voluntarily release and hold harmless the City of Beverly Hills from any liability or claim or action for damages which in any way arise out of my participation in the "Pay to Stay" program. In addition, I agree to be responsible and pay for any emergency or non-emergency medical treatment received while incarcerated in the Beverly Hills Police Department Jail, including paramedic transport. I understand that the Jail facility does not have trained medical staff on-site. By my signature below, I agree to the above.

Sign Name: Date:



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