Beruflich Dokumente
Kultur Dokumente
Fill Out Completely, Please Print or Type ALL INFORMATION IS REQUIRED Action Requested:
Privileged Visiting Basic Visiting Address Change Special Visit/Date Removal/Date Name Change 2 Year Renewal
Person Requested (name must match DMV records): Madrigal Visitors Name (printed)
nd
Jose
Last
Middle 97236
State
Email address (optional):______________________________________________________________ Age: 61 Birth Date:12/12/51 Sex: F MX State:OR Contact Phone: 503-894-8156
Does this person have a criminal conviction or imprisonment record? yes If yes: When, where and for what? OSP 1982-1983 Assault Has this visitor ever been a victim or co-defendant of your crime (past or present)? Victim: no__ Is this person currently on Parole or Probation? no . If yes, which agency and supervising officer? Co-Def. Yes__ No__
Is this person a current or former employee, volunteer, or contractor of the Department of Corrections? no__________ Is this person now visiting another inmate in this facility? Relationship of prospective visitor to the other inmate: Has this person ever been denied visiting privileges at any correctional facility or jail? no If yes, explain If this person is a minor, list the name, address, and phone number of the childs custodial parent or legal guardian: _______________________________________________________________________________________________________ Under penalty of possible disciplinary action and removal of this person from visiting, I certify that the information given above is true and does not contain misleading statements. Ball Inmates Name (printed) Fred Last First 7255311 Inmates Signature SID # Institution Unit Cell # Date Howard Middle Initial no If yes, who?
Note to inmate: If visiting privileges are denied, you have a right to request a review of the decision by submitting a written request to the Administrator of the Correctional Case Management Unit. Note to Prospective Visitor: At your option, you may return this form directly to the Correctional Case Management Unit by email to: DOC.Visitors@doc.state.or.us or fax to (503) 378-3763. You also may mail the form to 2575 Center St NE, Salem
CD 50 (7/12)
OR 97301. Submission of application does not constitute approval. Inmates have the right to refuse visiting requests made by prospective visitors.
CD 50 (7/12)