Bcso- Classification Form Request To Visit
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1Bristol County Sheriff’s Department
Request to Visit Form
The data supplied on this application will be used to obtain information, including criminal offender record Information (CORI
M.G.L. Chapter 6, sections 167-178). Do not leave questions blank-enter N/A if not applicable.
Mail completed forms to: BCSO
Attention: Communications Division
400 Faunce Corner Road
North Dartmouth, MA 02747
Date: _______________________
Phone #:________________________________________________
Name: ________________________________________________________________________________________________
Print
Last
First
Middle
Address: _______________________________________________________________________________________________
Number
Street Name
City/ State
Date of birth: _____________________________ Place of birth: __________________________________
Drivers License Number: ___________________________________________________________________________________
Permission to Visit with:
______________________________________________________________________________________
Print name of inmate
ID #
Relationship to inmate
: _______Spouse ________ Parent
________Child
________ Sibling
________Grandparent
________Cousin
______Significant other
______ Friend
______ Other: ____________________
(Please specify)
PLEASE ANSWER ALL QUESTIONS:
For Communications Purpose Only.
1. Have you ever been convicted of a felony?
(
) Yes
(
) No
_______________Date
If yes, a felony application needs to be completed prior to visiting
_____________ Disp.Initials
2. Are you presently on probation or parole?
(
) Yes
(
) No
BOP
Warrant
3. Have you ever been sentenced to a penal institution?
(
) Yes
(
) No
No Disposition
4. List any and all arrests, including out of state (year, arresting agency, charge)
Other _______________________
To be completed by BCSO personnel
------------------------------------------------------------------------------------------------------------------------------------------------------------------
A copy of this section is to be provided to the inmate so he or she may notify his/her visitor of the approval or denial.
To: ____________________________________________
______________
Inmate Name
ID #
Date
Name of visitor: ______________________________________________________________________________
After reviewing this visit request and all relevant information, I have decided to
( ) Approve this request
(
) Deny this request
Note:
REASON FOR DENIAL: ____________________________________________________________________________
________________________________________
____________________
Facility Deputy Superintendent or designee signature
Date
BCSO- Classification Form
Revised 05/17/2010
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