STATE OF NEVADA DEPARTMENT OF CORRECTIONS …
1. INMATE INFORMATION
STATE OF NEVADA DEPARTMENT OF CORRECTIONS
INMATE VISITING APPLICATION
FILE# ___________________(For Institutional use only)
Inmate Name: ________________________________________________________ Inmate I.D # _________________________
If you would like the privilege of visiting and your name placed on an Inmates visiting list, please complete this application. ALL questions MUST be answered. If the question does not apply place an "N/A" in the blank. Any omission or false statement is sufficient reason for permanent denial of visiting privileges. Please completed the application and send it to the Institution where the Inmate you wish to visit is located. All completed applications require ORIGINAL signatures prior to processing.
2. NAMES AND ADDRESSES
VISITING APPLICANT NAME: ________________________________________________________________________________
LAST
FIRST
MI
LIST ANY OTHER NAMES (ALIAS) YOUR KNOWN BY (INCLUDING YOUR MAIDEN NAME, IF APPLICABLE)
____________________________________________________ ____________________________________________________
____________________________________________________ ____________________________________________________
CURRENT ADDRESS: _______________________________________________________________________________________
FULL STREET ADDRESS
CITY
STATE
ZIP
CURRENT PHONE NUMBER: ___________________________ E-MAIL ADDRESS ____________________________________
PREVIOUS ADDRESS: _______________________________________________________________________________________
FULL STREET ADDRESS
CITY
STATE
ZIP
LIST OTHER STATES YOU HAVE LIVED IN: ___________________________________________________________________
OCCUPATION OR BUSINESS: ________________________________________________________________________________
EMPLOYER: ________________________________________________________________________________________________
HAVE YOU EVER WORKED FOR THE NEVADA DEPARTMENT OF CORRECTIONS? ______ IF YES WHEN ____________
IN WHAT CAPACITY ___________________________________ POSITION TITLE _____________________________________
3. IDENTIFIERS
DRIVER LICENCE NUMBER:___________________________________ STATE: ______________________________________
DOB:___________________________________ PLACE OF BIRTH: ______________________________________ AGE: _______
SSN# __________________________________
GENDER:
MALE ______ FEMALE ______
RACE: _________________________________
MARITAL STATUS: MARRIED ______ SINGLE _____
HEIGHT: ___________ WEIGHT: ____________ HAIR COLOR: __________________________ EYE COLOR: _____________
SCARS, MARKS, TATTOOS: __________________________________________________________________________________ ____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
DOC 3000 Inmate Visiting Application (11-12)
4. CRIMINAL HISTORY
HAVE YOU EVER BEEN ARRESTED? YES _____ NO _____ (If yes complete the following section; attach additional sheet if necessary)
CHARGE ____________________________
APPROXIMATE DATE _____________________
DISPOSITION _____________
CITY / STATE ____________
____________________________
_____________________
_____________
____________
____________________________
_____________________
_____________
____________
____________________________
_____________________
_____________
____________
ARE YOU CURRENTLY ON PROBATION / PAROLE? ______________ If yes what State? _____________________________
5. INMATE RELATIONSSHIPS
HOW LONG HAVE YOU KNOWN INMATE? _______________ RELATIONSHIP TO INMATE? _________________________
DO YOU NOW OR HAVE YOU EVER VISITED OR CORRESPONDED WITH ANOTHER NEVADA DEPARTMENT OF CORRECTIONS INMATE? ________
(If yes complete the following section)
NAME AND NUMBER __________________________________ __________________________________ __________________________________
RELATIONSHIP _______________ _______________ _______________
INDICATE WHETHER YOU WRITE OR VISIT _________________________________________ _________________________________________ _________________________________________
6. AUTHORIZATION
I have read, understand and agree to comply with the visiting rules of the Nevada Department of Corrections. I herby authorize the Department of Corrections to verify the criminal history information provided by me on this application.
APPLICANTS SIGNATURE _________________________________________________________ DATE ________________
*******If you are under 18 years of age, visiting approval will require the approval of your parent or guardian. Their signature MUST be notarized*******
SIGNATURE PARENT OR GUARDIAN _______________________________________________ DATE ________________
State of _____________________, County of ___________________
Signed and sworn to before me on ________________ by ___________________________________
(Date)
(Print name of person making statement)
____________________________________________ Notary Stamp:
(Signature of notarial officer)
__________________________________________________________________________________ DATE ________________
AGENCY AUTHORIZATION FOR RECORDS CHECK DATE
7. APPLICATION REVIEW
APPROVED _______ DISAPPROVED ________
______________________________________________________________________________ __________________________
SIGNATURE VISITING OFFICER
DATE
DOC 3000 Inmate Visiting Application (11-12)
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