Pima County Cleared Corrections Visitation (Ccv) Request
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1
2Pima County Adult Detention Center
Cleared Corrections Visitation (CCV) Request
Professional and Program Entry
All persons requesting access to secure areas of the Pima County Corrections Bureau must provide the following
information. This form is to be completed by the applicant. Information is for corrections visitor clearance only and
will not be disseminated in any manner. ALL INFORMATION MUST BE COMPLETEDOMISSION OF THIS
INFORMATION MAY RESULT IN DENIAL OR DELAY OF ACCESS TO FACILITIES. There are two forms, both
must be completed.
Circle one
Question
Yes
No
Have you ever been arrested?
Yes
No
Have you ever been incarcerated in a corrections facility?
Yes
No
Have you ever been on probation or parole?
Yes
No
Do you have any pending criminal charges?
Yes
No
Have you ever been charged with a sexual offense?
Yes
No
Have you ever been charged with an assault and/or assaulting a law enforcement officer?
Yes
No
Have you ever been charged with introducing contraband into a corrections facility?
Yes
No
Do you have any family members/acquaintances currently incarcerated?
Explain any YES answers on this form in detail. All applications are reviewed for criminal history checks and
warrants. Any information which indicates a possible compromise to security and safety of the institution
will be grounds for refusal.
Provide the following information completely, accurately and legibly. Nicknames and misspelled information will
delay or deny your request. This form is required for each individual requesting clearance and must be resubmitted
no more than two weeks prior to expiration or the clearance will expire without notice.
Full name: Last
First
Middle
Other Names Used
DL/ID#
Issuing State
Date of birth
Social Security #
Height:_____ Weight:_____
Sex:
M
F
Race
Home Phone
Other Phone
Home address
Apt #
City
State
Zip
(NO PO BOX)
(Contracted)Employer/Program/Company Tucson City Court
Job Title Interpreter
Supervisor/Program Coordinator Alma Dausinger
Phone (520)837-3130
Business Address 103 E. Alameda
City Tucson
State AZ
Zip
85701
Business Phone (520)837-3130
Business Fax
Reason For Request
Interpreter assignments for in custody defendants with matters pending before the court.
The Corrections Bureau is subject to Federal guidelines pertaining to the release of confidential information. If you
have been denied clearance you may request in writing a response for the denial.
PCADC USE ONLY
Denied
Date:
SID#
Staff PR:
Approved and Type:
FBI#
First Cleared:
Expiration Date:
NAME #
Date Received:
Revised 01/13
Information on this document is used specifically for clearance into the facilities and will not be
used for any other purpose. This document will be destroyed at the conclusion of its retention date.
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