Form Csc/scc 0653e - Visiting Application And Information Form printable pdf download

Correctional Service

Service correctionnel

PROTECTED

ONCE COMPLETED

Canada

NOTE: Reference document

CD559

PERSONAL INFORMATION BANK

►

PUT AWAY ON FILE

Original = Offender VC file

►

FPS Number

VISITING APPLICATION

Family name (name

►

of inmate you wish

to visit)

NOTE: Shaded areas are for office use only

►

Given name(s)

Institution

Region

►

Date of birth

Completing Operational Unit

IMPORTANT

PLEASE READ THIS FORM CAREFULLY. Answer all questions and sign in the applicable spaces. You are also required to submit with this

application TWO CURRENT PHOTOGRAPHS of yourself (full face view, head and shoulders only) minimum size 5 cm x 3.5 cm (2" x 1 1/2"). Send

your completed application with photographs to the institution (refer to the CSC site for the appropriate address of the institution)

NOTE: Failure to complete the form fully will result in delays in the visitor approval process. Providing false information is sufficient to deny

access.

PRIVACY ACT STATEMENT

Personal information about you is collected under the authority of the Corrections and Conditional Release Act to review your suitability for visiting privileges

at the CSC. This information is collected, with no obligation on your part, and held in the Visits and Correspondence Bank; however, your refusal to comply

would result in the denial of visiting privileges. This information cannot be disclosed to other persons without your consent EXCEPT where disclosure would

be justified pursuant to one of the paragraphs of subsection 8(2) of the Privacy Act.

INFORMATION ON APPLICANT

Your name

Your date of birth

Your place of birth

Maiden name

Family name

Given names (in full)

YYYY-MM-DD

City/Town

Province/Country

(if applicable)

Your present address

Apt. no.

City

Province

Postal code

No.

Street

Telephone no. where a CSC representative

Motor vehicle

Your telephone no.

Your physical description

could contact you if necessary

licence no.

Colour of

Home

Height

Weight

At work OR

Other than home phone

hair

eyes

(

)

(

)

(

)

I am the inmate's

Father

Mother

Spouse

Common-law partner

Brother

Sister

Son

Daughter

I am a victim of an offence committed by this offender

►

Other (volunteer, friend, cousin, aunt, uncle) (specify type and length of relationship):

Explain if extenuating circumstances

Name of person and his/her telephone no. where a CSC

(

)

representative may contact in an emergency

Name

(print)

Telephone no.

Are you on another inmate's visiting list?

Are you a volunteer visitor at this or any other institution?

Yes

If YES, state inmate's name, your relationship to him/her and which

If YES, state the name of the group or program you take part in and the

institution he/she is in.

institution's name.

►

CSC/SCC 0653E (R-2015-07) (PDF)

Information may be accessible or protected as required under the provisions

DISTRIBUTION

(Voir CSC/SCC 0653F pour la version française)

of the Access to Information Act and the Privacy Act.

Page 1 of 3

Copy= Security Intelligent Officer

Form Csc/scc 0653e - Visiting Application And Information Form

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