Guilty plea submission form

1. Details of hearing

   1. Which courthouse are you to appear in? * The courthouse listed on your notice. —please select— Atherton Magistrates Court Ayr Magistrates Court Bamaga Magistrates Court Barcaldine Magistrates Court Beaudesert Magistrates Court Beenleigh Magistrates Court Biloela Magistrates Court Blackall Magistrates Court Blackwater Magistrates Court Bowen Magistrates Court Brisbane Magistrates Court (George St) Brisbane Arrest Court (Roma St) Bundaberg Magistrates Court Caboolture Magistrates Court Cairns Magistrates Court Caloundra Magistrates Court Charleville Magistrates Court Charters Towers Magistrates Court Cherbourg Magistrates Court Childers Magistrates Court Chinchilla Magistrates Court Clermont Magistrates Court Cleveland Magistrates Court Cloncurry Magistrates Court Cooktown Magistrates Court Coolangatta Magistrates Court Cunnamulla Magistrates Court Dalby Magistrates Court Emerald Magistrates Court Gatton Magistrates Court Gayndah Magistrates Court Gladstone Magistrates Court Goondiwindi Magistrates Court Gympie Magistrates Court Hervey Bay Magistrates Court Holland Park Magistrates Court Hughenden Magistrates Court Ingham Magistrates Court Innisfail Magistrates Court Ipswich Magistrates Court Julia Creek Magistrates Court Kingaroy Magistrates Court Landsborough Magistrates Court Longreach Magistrates Court Mackay Magistrates Court Mareeba Magistrates Court Maroochydore Magistrates Court Maryborough Magistrates Court Millmerran Magistrates Court Mitchell Magistrates Court Moranbah Magistrates Court Mossman Magistrates Court Mount Isa Magistrates Court Murgon Magistrates Court Nambour Magistrates Court Nanango Magistrates Court Noosa Magistrates Court Normanton Magistrates Court Oakey Magistrates Court Pine Rivers Magistrates Court Pittsworth Magistrates Court Pomona Magistrates Court Proserpine Magistrates Court Quilpie Magistrates Court Redcliffe Magistrates Court Richlands Magistrates Court Richmond Magistrates Court Rockhampton Magistrates Court Roma Magistrates Court Roma Street Arrest Court St George Magistrates Court Sandgate Magistrates Court Sarina Magistrates Court Southport Magistrates Court Springsure Magistrates Court Stanthorpe Magistrates Court Taroom Magistrates Court Thursday Island Magistrates Court Toogoolawah Magistrates Court Toowoomba Magistrates Court Townsville Magistrates Court Tully Magistrates Court Warwick Magistrates Court Weipa Magistrates Court Wynnum Magistrates Court Yarrabah Magistrates Court Yeppoon Magistrates Court

   2. Please note

      You have chosen Roma Magistrates Court.

      If you are to appear in the Brisbane Arrest Court in Roma Street, please choose Brisbane Arrest Court (Roma St) or Roma Street Arrest Court from the drop down list.

   3. Please note

      You have chosen St George Magistrates Court.

      If you are to appear in the Brisbane Magistrate Court located on George Street, please choose Brisbane Magistrates Court (George St) from the drop down list.

   4. Please note

      You have chosen Brisbane Magistrate Court (George St).

      If you are to appear in the Brisbane Arrest Court located on Roma Street, please choose Brisbane Arrest Court (Roma St) from the drop down list.

   5. Please note

      You have chosen Brisbane Arrest Court (Roma St).

      If you are to appear in the Brisbane Magistrate Court located on George Street, please choose Brisbane Magistrates Court (George St) from the drop down list.

   6. What date are you required to attend? * The date of the hearing listed on your notice. Example: 12/07/2014
2. Details of offence

   1. What offence(s) were you charged with? *
   2. Date of offence(s) * Example: 26/01/2014
   3. Occurrence number (if known)
3. Information for magistrate

   1. What would you like the magistrate to take into account when deciding your sentence? Please provide as much information to help the magistrate understand.
4. Legal representation

   1. Is a lawyer representing you? *

      • Yes
      • No
   2. Legal practitioner details (If you chose ‘Yes’ above)

      1. Legal practitioner's name

         1. Given name *
         2. Family name *
      2. Name of firm *
5. Your details

   1. Name

      1. Given name/s *
      2. Family name *
   2. Email address Example: jane.smart@example.com
   3. Phone * Home, mobile or work number
   4. How would you prefer we contact you? * —please select—EmailPhone
6. Your address

   1. 1. Address line 1 *
      2. Address line 2
      3. 1. Town, city or suburb *
         2. State *
         3. Postcode *
      4. Country *
   2. Is your postal address the same as residential? *

      • Yes
      • No
   3. (If you chose ‘No’ above)

      1. Postal address

         1. Address line 1 *
         2. Address line 2
         3. 1. Town, city or suburb *
            2. State *
            3. Postcode *
         4. Country *
7. Acknowledgements

   1. Acknowledgement

      * I acknowledge I may plead guilty or not guilty. I acknowledge that no police officer or any other person has told me I must or should plead guilty.
   2. Acknowledgement

      * I plead guilty to the offence listed in this form. This plea is entered voluntarily and of my own free will.
   3. Acknowledgement

      * I understand that I will be liable to pay the offender levy of $147.60.
   4. Acknowledgement

      * I acknowledge that a copy of my completed form will be provided to the Queensland Police Service.