Form Dc6-111a - Request For Visiting Privileges Application printable pdf download

2 Part Form

Florida Department of Corrections

APPLICATION

Part 1: Visiting Request

REQUEST FOR VISITING PRIVILEGES

Part 2: Visitor Information

[Part 1 of 2]

More Visitation Information at:

After completing this form mail to:

Please DO NOT visit until the inmate

notifies you of your approval

Please read this carefully: Only one form per person.

• This inmate requests you be approved for visitation privileges. To do this, we must have the following information about you.

• DO NOT LEAVE blanks, doing so will cause your application to be DENIED. When items do not apply, write in NA (not applicable).

• Supplying false or misleading information results in your application being denied.

• Persons 12 years old and older wanting to visit must complete this form. Be sure to sign the form in the space provided or it will not be processed.

Continue on attached sheet if necessary for any item

1. Inmate Name

2. Inmate's Department of Correction Number (DC#)

3. Your Relationship to the Inmate:

(mother, friend, penpal,etc)

4. Are You a Victim of This Inmate’s Crime?

Yes

First name:

5. Complete Legal Name:

Last name:

Middle name:

Date of Birth:

Age:

6. Identifying Information:

Race:

Sex:

Driver’s License or State ID No. (16 yoa. and older)

State

Number

Physical Address/Apt. # :

7. Complete Home Address:

City:

County

State:

Zip Code

Home

(include area code)

8. Phone Numbers:

Work

(include area code) :

9. Employment Status:

Place of Employment:

Have you ever worked for the Florida Dept. of Corrections (employee, volunteer, contractor, vendor, etc.):

Yes

* List dates, location, and positions held:

10. Background:

Have you ever been arrested?:

Yes

Did you ever help this inmate commit a crime?:

Yes

Were you ever in prison?

Yes

Dates & Location of each imprisonment:

Prison #

What were you convicted of for each imprisonment?:

Are you currently on Probation/Parole?:

Yes

If yes, which agency is supervising you (Circle one)?:

State

Federal

County

Dept. of Juv. Justice

Other

If Probation/Parole has been terminated, indicate date of termination:

What are you on probation/parole for?:

Name of Probation Officer:

Phone number of Probation Officer:

11. Are you approved to visit any other inmate?:

Yes

What is their name(s) and DC#(s)?:

Name:

DC#:

12. Have your visitation privileges ever been denied,

Yes

suspended, or terminated?

Please explain:

13. Where did you meet this inmate (Circle one)?:

Pen pal Neighborhood Work Family Prison Other

I certify all the information above is complete, accurate, true and that I have read all of the Visitor Rules in Part 2 of this application and

agree to follow these rules. In addition, I understand that giving false information is a second-degree misdemeanor and could result in the

permanent suspension of my visiting privileges. I acknowledge that a criminal background check will be made.

Signature

Date

Print Name

(Last, First, Middle Name)

Signature

Date

Print Name

of Parent or Legal Guardian if under 18 years

(Last, First, Middle Name)

old

DC6-111A (Revised 8/07)

NOTICE TO ALL VISITORS: Carefully read the attached policies before visiting.

PLEASE DO NOT VISIT UNTIL THE INMATE NOTIFIES YOU YOUR APPLICATION IS APPROVED

Incorporated by Reference in Rule 33-601.737, F.A.C.

Form Dc6-111a - Request For Visiting Privileges Application

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