REQUEST FOR VISITING PRIVILEGES APPLICATION

1 2 Part FormPart 1: VISITING RequestPart 2: Visitor InformationFlorida Department of CorrectionsREQUEST FOR VISITING PRIVILEGES [Part 1 of 2]APPLICATIONMore Visitation Information DO NOT VISIT UNTIL THE INMATE NOTIFIES YOU YOUR APPLICATION IS APPROVEDI ncorporated by Reference in Rule , DO NOT visit until the inmate notifies you of your approval . After completing this form mail to: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.

2 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 on attached sheet if necessary for any item1. Inmate Name2. Inmate's Department of Correction Number (DC#)3. Your Relationship to the Inmate:(mother, fr iend, p enpal,etc)4.

3 Are You a Victim of This Inmate s Crime?No 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)StateNumberPhysical Address/Apt. # :7. Complete Home Address:City:CountyState:Zip Code8. Phone Numbers:Home (include area code):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.)

4 : No Yes* List dates, location, and positions held:10. Background:Have you ever been arrested?:No YesDid you ever help this inmate commit a crime?:No YesWere you ever in prison?:No YesDates & Location of each imprisonment: Prison #What were you convicted of for each imprisonment?:Are you currently on Probation/Parole?:No YesIf yes, which agency is supervising you (Circle one)?:State Federal County Dept.

5 Of Juv. Justice OtherIf 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?:No YesWhat is their name(s) and DC#(s)?:Name:DC#:12. Have your visitation PRIVILEGES ever been denied,No Yessuspended, or terminated? Please explain:13. Where did you meet this inmate (Circle one)?:Pen pal Neighborhood Work Family Prison OtherI 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.

6 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 Name (Last, First, Middle Name)Signature of Parent or Legal Guardian if under 18 years oldDatePrint Name (Last, First, Middle Name)DC6-111A (Revised 8/07)NOTICE TO ALL VISITORS: Carefully read the attached policies before APPLICATION ONLYUPDATED APPLICATION AVAILABLE FROM INMATE ONLYDO NOT USEF ormulario en 2 PartesParte 1: Petici n para VisitasParte 2.

7 Informaci n para el VisitanteDepartamento de Correction de La FloridaPETICI N DE PRIVILEGIOS PARA VISITAS[Parte 1 de 2]ENGLISH VERSION IS ON THE NPara M s informaci n Sobre favor, no venga a visitar hasta que usted sea notificado por el preso que usted ha sido de llenar este formulario, devuelvalo a:Por favor, lea esto cuidadosamente: El preso arriba nombrado, ha pedido que usted sea aprobado para visitarlo. Para hacer esto, debemos tener la siguiente informaci n acerca de usted. No deje ning n espacio en blanco; porque si no, su aplicaci n ser denegada.

8 Escriba NA (no aplicable) en el espacio dejado en blanco. Dar informaci n falsa enga osa, resultar en que su aplicaci n sea denegada. Personas mayores de 12 a os de edad, que deseen visitar, deber n llenar esta planilla en su totalidad. Aseg rese de firmar la planilla en el espacio indicado porque la planilla no ser procesada si no est e en una hoja adjunta si es Nombre del Preso:2. DC #:3. Cu l Es su Relaci n con el Preso: (madre, padre, amigo, etc.)4. H sido usted v ctima de este preso?

9 No S Apellido:5. Nombre Legal Completo:Primer nombre: Segundo nombre:Fecha de nacimiento:Edad:6. Informaci n de Identidad:Raza:Sexo: Licencia de Conducir: (16 a os de edad o mayor)Estado:N mero:Direcci n f sica/Apartamento #:7. Direcci n Completa:Ciudad:Condado:C digo postal:8. N meros de Tel fonos:Casa (incluya el rea):Trabajo (incluya el rea):9. Empleo:Lugar de empleo: Ha sido usted empleado por el Departamento de Correcciones de La Florida?: No S Aplicaci n Pendiente Ha Como voluntario, interno, empleado bajo contracto vendedor de FDC?

10 :No S Encierre en un c rculo cualAnote fechas, lugar, y tipo de empleo:10. Antecedentes: H sido ud. alguna yez arrestado?No S H usted alguna vez ayudado a este preso a cometer un crimen?:No S H estado usted alguna vez en prisi n?:No S Fechas de cada vez que ha sido puesto en prisi n y n mero de prisi n: D qu fu usted condenado cada vez que estuvo en prisi n?: Est usted actualmente bajo probaci n/bajo palabra?Si S , c al agencia lo est supervisando?