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.) Last:          First M.I.:
Residence Address: Street:  
City:                State: Zip:
Date of Birth (mm/dd/yyyy): Sex:
Race: SSN:
Driver's License Number: Issuing State:
Residence/Home Phone: Work Phone:
Cell Phone: Fax:
Email Address:  

Emergency Contact Information
Contact Name
(Last, First M.I.):
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:  
Court Case Number:
Court of Jurisdiction:
Charge(s) Convicted of:
Length of Sentence:
By what date do you need to complete this sentence? (mm/dd/yyyy)
When do you need to begin serving your sentence? (mm/dd/yyyy)
Name, address and phone number of your Attorney of Record in this case:

C. Employment Information
Employment Status:
Name/Address of Employer:    
Name of Supervisor: Supervisor's Phone:  
Name/Address of School:
Name of Advisor or Contact: Advisor/Contact Phone:  

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?    
  : Type of Inhaler    
    : Type and Frequency   :
Have you had any major surgery?   If Yes, please provide explanation and how long ago:
Have you ever been admitted to a Psychiatric Hospital?   If Yes, please explain:

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

   If Yes, please explain
Have you had any head injuries in the last 60 days?   If Yes, please explain

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

  If Yes, where?
Have you ever attempted suicide?   If Yes, please explain:

Are you thinking of suicide?

  If Yes, please explain:

Are you taking or need to take any prescription medication?

  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.

Type Name: Date (mm/dd/yyyy):