Application To Visit An Inmate Page 2
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2Responses to all questions are required, check either yes or no.
Visitor Information Section Cont'd
Are you the victim of the crime for which the inmate is currently incarcerated?
Yes
No
Are you on the visiting list of any other inmate in this or any other correctional institution
in Arizona?
(Jail, detention center or prison)
Relationship to inmate ________________
Yes
No
If yes, other inmate's name ____________________________________________
ADC Number
_______________________
Are you, or have you ever been on probation in any state?
?)
(Supervised or unsupervised
Yes
No
If yes, give the name(s) and location of the Court(s) ______________________________ Dates: from__________ to __________
Are you, or have you ever been on parole in any state?
Yes
No
If yes, give the name(s) and location of the Court(s) ______________________________ Dates: from__________ to __________
Have you ever been confined to any correctional institution in any state?
?)
(Jail, detention center or prison
Yes
No
If yes, give name and location of facility(s)___________________ Number ____________ Dates: from__________ to __________
Have you ever been suspended from visiting an inmate in any state?
(Jail, detention center or prison?)
Yes
No
If yes, name of institution ________________________ Inmate Name_________________________ Inmate Number____________
Are you related to any other inmate in any correctional institution in Arizona?
(If more than one, list all others on a separate piece of paper.)
Yes
No
If yes, inmate name _______________________________________
Inmate Number ____________________________________
Institution
Relationship to inmate
Have you ever been employed by or volunteered for the Arizona Department of Corrections?
Yes
No
If yes, when? _________________________ Where ? ______________________________ Position _______________________
I hereby attest that the answers to all of the questions are true and correct. I agree to abide by all visitation rules of the
Arizona Department of Corrections. I understand that a one-time Background Check Fee of $25.00 will be assessed
regardless of approval/denial for all adult visitors. This application will not be processed until the $25.00 Background Check
Fee, if required, is received.
Date
Applicant or Minor's Parent or Legal Guardian Signature
DO NOT WRITE BELOW THIS LINE
Date Run
Initials
Fee Collected:
NCIC
Electronically:
ACIC
Mailed:
CCH
Criminal History Practitioner _______________________________________________
Date
Warden or Designee Signature
Approved
Disapproved
911-4
1/21/12
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