DOC Background Check Form

Visit List Verification

(to be completed by the inmate or applicant)

Inmate Name:

Inmate #:

Unit:

Cell #:

The following family members may be eligible to be placed on an inmate's visit list. All visitors are subject to a criminal background check.

Spouse	Sister	Half-Brother		Son-in-law	Legal Guardian	AA/NA Sponsor
Child	Step-Brother	Grandchild	Great Grandparent	Daughter-in-law	Friend (Max of 4)	Media Representatives
Parent	Step-brother	Grandparent	Mother-in-law	Sister-in-law	Attorney of Record	Clergy
Brother	Half-sister		Father-in-law	Brother-in-law	M-2/W-2 Sponsors

Complete information is required. Alisases or nicknames will not be accepted. P.O. Boxes are not accepted for a "physical address". Social Security numbers must be provided for all visitors age 18 or older for the purpose of conducting a criminal background check. Applications containing incomplete information will not be considered.

Male

Female

Full Name:

Maiden Name/Alias

Relationship to Inmate

Social Security #

DoB (MM-DD-YYYY)

Street Address/P.O. Box

City

State

Zipcode

Driver License #

Phone Number

Male

Female

Full Name:

Maiden Name/Alias

Relationship to Inmate

Social Security #

DoB (MM-DD-YYYY)

Street Address/P.O. Box

City

State

Zipcode

Driver License #

Phone Number

Male

Female

Full Name:

Maiden Name/Alias

Relationship to Inmate

Social Security #

DoB (MM-DD-YYYY)

Street Address/P.O. Box

City

State

Zipcode

Driver License #

Phone Number

Male

Female

Full Name:

Maiden Name/Alias

Relationship to Inmate

Social Security #

DoB (MM-DD-YYYY)

Street Address/P.O. Box

City

State

Zipcode

Driver License #

Phone Number

Male

Female

Full Name:

Maiden Name/Alias

Relationship to Inmate

Social Security #

DoB (MM-DD-YYYY)

Street Address/P.O. Box

City

State

Zipcode

Driver License #

Phone Number

Staff Name

Staff Unit

Date

NOTE: Applicants may choose to mail/deliver the completed form directly to the facility. All information provided shall remain confidentail and will not be shared with inmates.