MISSISSIPPI DEPARTMENT OF CORRECTIONS

VISITOR REGISTRATION FORM

INMATE: ____________________________________________ MDOC #: ______________________

VISITOR’S NAME: _____________________________________ DATE OF BIRTH: _______________

VISITOR’S ADDRESS: ___________________________________ PHONE #: ___________________

CITY, STATE, ZIP CODE: ________________________________________________________

VISITOR’S SS# _______- ____- ________ RACE: __________ SEX: M _______ F ________
____________________________________________________________________________
The above named inmate has requested you as a possible addition to his visiting list, with the hope that
this will aid in maintaining their family ties. All information requested must be provided in order to
place you on this offender’s visitation list.

What is your relationship to this offender? ______________________________________

Have you ever been convicted of a felony? Yes_____ No_____

Have you ever been incarcerated? Yes_____ No_____ If yes, give dates: ________________________
Location and D.O.C. Number: ___________________________________________________________

If you are a female, and have been married, what is your maiden name? _________________________

If you have children with this inmate as the father, please state their full names and ages:

______________________________________ _______________________________________

______________________________________ _______________________________________

Are you or have you ever been on probation or parole? If yes, give dates.
From_________ To ___________

Have you ever or are you currently employed with the Mississippi Department of Corrections, including
contractual services (i.e. food services, medical services)? Yes_____ No_____ If yes, when_________,
where __________

Are you related to any other inmate in this facility or any correctional facility in Mississippi? Yes_______
No_____ If yes, give name, MDOC number, location and relationship: ___________________________
___________________________________________________________________________________

Are you presently visiting any other inmate in this or any correctional facility in Mississippi?
Offender Name ______________________ MDOC # _________ Name of Facility__________________

NOTE! ALL VISITORS MUST BE OVER THE AGE OF EIGHTEEN

(18) YEARS OF AGE TO VISIT WITH AN INMATE UNLESS
Return Form to: KNRCF
ACCOMPANIED BY A PARENT OR GUARDIAN. Visitation Department
300 Industrial Park Road
31-03-01 F-2
Revision 03/01/04
DeKalb, MS 39328
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