Request For Permission To Travel Form
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1REQUEST FOR PERMISSION TO TRAVEL
(Not Valid Without Client Signature)
Return to:
____
U.S. Probation
_____
U.S. Probation
th
400 Congress St., 5
Floor
202 Harlow Street, Rm. 209
Portland, ME 04101
Bangor, ME 04401
Tel:
(207) 780-3358
Tel:
(207) 945-0369
Fax:
(207) 780-3784
Fax:
(207) 945-0305
1)
NAME: ________________________________________________________________
(Last)
(First)
(Middle)
2)
ADDRESS:
__________________________________________________________
(Street Address and Number)
_____________________________________________________
(State and Zip Code)
3)
REQUEST FOR PERMISSION TO TRAVEL TO:
_________________________________________________________________________
_________________________________________________________________________
4)
YOU WILL TRAVEL BY:
___ Automobile
___ Airline ___ Bus ___ Railway
5)
NAME OF PERSON, PLACE AND TEL. NO. WHERE YOU WILL RESIDE:
1)
PERSON: ___________________________________________________________
2)
ADDRESS:
_____________________________________________________
____________________________________________________________________
3)
TELEPHONE: Area Code and Number: _________________________________
6)
NAME OF PERSON(S) TRAVELING WITH YOU: _______________________________
____________________________________________________________________________
7)
STATE FULLY YOUR REASON FOR REQUESTING THIS PERMISSION: __________
_____________________________________________________________________________
_____________________________________________________________________________
8)
WHEN DO YOU EXPECT TO LEAVE: _________________________________________
9)
WHEN DO YOU EXPECT TO RETURN: ________________________________________
CLIENT SIGNATURE: __________________________________ DATE: ____________________
PERMISSION GRANTED ______
PERMISSION DENIED _____
SIGNATURE OF PROBATION OFFICER ______________________________________________
DATE: ___________________________________
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