Department Of Corrections Visitor Application

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DC Form 300-01A (12/15/13)
STATE OF COLORADO
DEPARTMENT OF CORRECTIONS VISITOR APPLICATION
FACILITY ADDRESS ADDED HERE
Dear Sir or Madam:
Offender Name
DOC Number
has requested you be given an application to visit them in the
Colorado Dept. of Corrections. If you wish to visit this offender you must complete this application and return it to the address above. If you do not wish
to visit this offender please ignore this letter. For more information regarding ADA accommodations, visit
and click “Visiting” or see
Administrative Regulation 100-42.
Do you require the use of a service animal to visit? ________YES__________NO
Your Name:
Date of Birth ____/____/____
Last
First
MI
Maiden Name: ________________________________ SSN:
-
-
(Optional)
Address: ____________________________________________________
________________
______
__________
Residential address
Apt # or Lot #
City
State
Zip code
Home Phone ______/_______-______________________
Work/Other Phone ______/_______-______________________
Drivers License/State Identification Card Information: (ATTACH COPY OF DRIVER’S LICENSE OR STATE ID)
State issued:
Number: ___________________ Date Issued: ____/____/____ Expiration: ____/____/____
Are you related to this offender? __________Yes __________ No
What is the relationship: ____________________________________________________________________________________
Are you an immediate family member of this offender? __________ Yes
No
(Immediate family member is defined as: Grandparents, parents, step-parents, adoptive parents, legal guardian, brother, step or half-brother, sister,
step or half-sister, spouse, son, daughter, step/foster/adopted children, and grandchildren.)
If you are not related to the offender, how long have you known this person? ___________________________________________
If you are not related to the offender, where/how did this relationship develop? _________________________________________
Are you now or have you been on another offender’s visiting list in the past twelve months.
Yes
No
If yes explain who, when, and why: ______________________________________________________________________________
___________________________________________________________________________________________________________
Are you employed, or have you ever been employed, or worked in a Colorado prison or private prison?
Yes
No
Have you or a family member ever been employed by the Colorado DOC, private prisons, or previously been a DOC/private prison volunteer?
______Yes ______No(If yes, when and at which facilities/office)_________________________________
Are you currently corresponding/volunteering or visiting with another offender at this or another facility? _____Yes ______No (If yes, offender
name and number.)__________
Have you ever been arrested or charged for any crime or complaint? ________Yes _______No (If yes,
List all dates)________________________________________________________________________
Are you presently on probation, parole, or [any form of criminal justice supervision]? _____Yes ___No (If yes, provide probation/parole officer
name and phone number.)________________________________________________
Has any member of your family (other than offender above) ever been incarcerated at a penal institution? ______Yes _____No (If yes, list all
name(s) and relation.)__________________________________________________________________________
Will you be bringing any minor children (under age 18) to visit this offender with you? If so, provide the following information for each minor
child that will be visiting this offender with you: (A minor may only visit in the company of his/her parent or legal guardian. If you are not the
parent or legal guardian of the minor child, you must provide a notarized statement (Attachment 300-01J) completed by the parent who gives you
permission to bring the minor child for visitation with this offender. A copy of the birth certificate for each minor child is required. The statement
will be kept on file at the facility.) (There must be a separate document for each minor child.)
Name
Last
First
Address
Date of Birth
Relation to Offender
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
CERTIFICATION: I certify that all the statements on this form are true. I understand that false information can delay the application process and can also
be cause to deny my application for up to 1 year if it is shown to be intentional. I also understand that my visiting status may be inactivated, after being
approved, if it is found that information on this form is falsified. I hereby authorize any representative of the Colorado Department of Corrections bearing
this release to obtain any information pertaining to my personal background and activities from Criminal Justice and Motor Vehicle agencies. This
information will include Criminal record information. I understand that the information is for official use only by the Colorado Department of Corrections
for determining eligibility to enter a Colorado Correctional Facility for the sole purpose of visiting an Offender. If a criminal records investigation reveals
criminal charges without disposition, I will provide a court order or similar legal document which stipulates what disposition was made of the charge(s),
before the application process will continue.
Applicant Signature
Date ____________________
Failure to complete this form will delay the processing of this request. You will not be allowed to visit until this request is processed.
Attachment “A”
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