Cdcr 106-A - Confidential Phone Call Request Form

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STATE OF CALIFORNIA
DEPARTMENT OF CORRECTIONS AND REHABILITATION
CONFIDENTIAL PHONE CALL REQUEST
CDCR 106-A (02/08)
READ CAREFULLY. Please PRINT or TYPE. The information requested will be used by officials of the California Department of Corrections and Rehabilitation
(CDCR) to determine whether your questionnaire will be approved or disapproved. The information provided will be maintained in a file pertaining to the inmate.
In accordance with the Privacy Act of 1974 (PL93-579), providing your Social Security number is optional. However, any omission or falsification on this
questionnaire may be cause for denial of the confidential phone call. Please mail this form directly to the Litigation Coordinator's office of the institution where
the inmate is confined.
1. NAME OF INMATE YOU WANT TO CALL (LAST, FIRST, MIDDLE)
INMATE'S CDC NUMBER
2. YOUR NAME (Print your name exactly as indicated on the photo identification you will be using)
SUFFIX (Jr., Sr., etc.)
OFFICE TELEPHONE NUMBER
(
)
3. MAIDEN NAME (If applicable)
HAVE YOU EVER USED ANOTHER NAME? IF SO, PLEASE LIST
FAX NUMBER
(
)
4. DATE OF BIRTH (Mo/Day/Yr)
AGE
GENDER (Check one)
BIRTHPLACE
(City
County
State
Country)
MALE
FEMALE
5. ID NUMBER
ID TYPE
BAR / P. I . NUMBER
BAR STANDING (Check one)
DRIVER'S LICENSE
Verified
Unverified
OFFICIAL USE ONLY
ISSUED BY:
(County
State
Country)
6. SOCIAL SECURITY NUMBER (Optional)
EXPIRATION DATE:
7. CURRENT MAILING ADDRESS: STREET ADDRESS
Apt. # (If Applicable)
CITY
STATE
ZIP CODE
8. HAVE YOU EVER BEEN CONVICTED OF A FELONY?
If YES, complete Item 9A. List all detentions, arrest and convictions. Failure to list all requested
information may result in denial of your confidential phone call. Attach additional sheet(s) if necessary.
Yes
No
9. OFFENSE (Check one)
APPROX. DATE
DISPOSITION: (Dismissed, Probation, Jail, Prison)
COUNTY
STATE
.
*Attorney or Attorney's representative must provide a written request, on official letterhead, indicating the purpose for the confidential phone call
________________________________________________________
_____________________________________________________________
Signature of Requestor
Date
Signature of CLETS Operator
Date
_______________________________________________
APPROVED
DISAPPROVED
Signature of Litigation Coordinator
Date
OFFICAL USE ONLY – TO BE COMPLETED BY INSTITUTION STAFF
APPROVED
DISAPPROVED
(If DISAPPROVED, the applicant is to be informed in writing of the disapproval.)
REASON FOR DISAPPROVAL:
PRINT NAME
SIGNATURE
TITLE
INSTITUTION
DATE

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