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2 Part Form |
Florida Department of Corrections |
APPLICATION |
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Part 1: Visiting Request |
REQUEST FOR VISITING PRIVILEGES |
More Visitation Information at: |
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Part 2: Visitor Information |
[Part 1 of 2] |
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www.dc.state.fl.us |
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After completing this form mail to:
Please DO NOT visit until the inmate notifies you of your
approval.
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.
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 processed.
Continue on attached sheet if necessary for any item
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1. Inmate Name |
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2. Inmate's Department of Correction Number (DC#) |
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3. Your Relationship to the Inmate: |
(mother, friend, penpal,etc) |
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4. Are You a Victim of This Inmate’s Crime? |
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No |
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Yes |
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First name: |
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5. Complete Legal Name: |
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Last name: |
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Maiden name: |
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Middle name: |
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Date of Birth: |
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Age: |
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6. Identifying Information: |
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Race: |
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Sex: |
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Driver’s License or State ID No. (16 yoa. and older) |
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State |
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Number |
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Physical Address/Apt. # : |
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7. Complete Home Address: |
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City: |
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County |
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State: |
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Zip Code |
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8. Phone Numbers: |
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Home (include area code): |
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Work (include area code) : |
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9. Employment Status: |
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Place of Employment: |
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Have you ever worked for the Florida Dept. of Corrections (employee, volunteer, contractor, vendor, etc.): |
No Yes |
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* List dates, location, and positions held: |
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10. Background: |
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Have you ever been arrested, or received a criminal citation, |
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No |
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Yes |
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or a notice to appear in court to respond to criminal charges? |
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Did you ever help this inmate commit a crime?: |
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No |
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Yes |
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Were you ever in prison?: |
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No |
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Yes |
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Dates & Location of each imprisonment: |
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Prison # |
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What were you convicted of for each imprisonment?: |
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Are you currently on Probation/Parole?: |
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No |
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Yes |
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If yes, which agency is supervising you (Circle one)?: |
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State |
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Federal |
County |
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Dept. of Juv. Justice |
Other |
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If Probation/Parole has been terminated, indicate date of termination: |
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What are you on probation/parole for?: |
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Name of Probation Officer: |
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Phone number of Probation Officer: |
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11. Are you approved to visit any other inmate?: |
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No |
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Yes |
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What is their name(s) and DC#(s)?: |
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Name: |
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DC#: |
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12. Have your visitation privileges ever been denied, |
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No |
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Yes |
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suspended, or terminated? |
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Please explain: |
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13. Where did you meet this inmate (Circle one)?: |
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Pen pal |
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Neighborhood |
Work |
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Family Prison |
Other |
I 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. 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 made.
Signature |
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Date |
Print Name (Last, First, Middle Name) |
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Signature of Parent or Legal Guardian if under 18 years old |
Date |
Print Name (Last, First, Middle Name) |
DC6-111A (Effective 12/14) |
NOTICE TO ALL VISITORS: Carefully read the attached policies before visiting. |
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PLEASE DO NOT VISIT UNTIL THE INMATE NOTIFIES YOU YOUR APPLICATION IS APPROVED
Incorporated by Reference in Rule 33-601.715, F.A.C.
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Formulario en 2 Partes |
Departamento de Correction de La Florida |
APLICACIÓN |
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Parte 1: Petición para Visitas |
PETICIÓN DE PRIVILEGIOS PARA VISITAS |
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Parte 2: Información para el Visitante |
Para Más información Sobre Visitas: |
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[Parte 1 de 2] |
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www.dc.state.fl.us |
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ENGLISH VERSION IS ON THE REVERSE. |
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Por favor, no venga a visitar hasta que usted sea |
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Despues de llenar este formulario, devuelvalo a: |
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notificado por el preso que usted ha sido |
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aprobado. |
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Por favor, lea esto cuidadosamente: Solo un formulario por persona.
El preso arriba nombrado, ha pedido que usted sea aprobado para visitarlo. Para hacer esto, debemos tener la siguiente información acerca de usted.
No deje ningún espacio en blanco; si lo hace, su aplicación será DENEGADA. Escriba NA (no aplicable) cuando algo no aplica a usted.
Dar información falsa ó engañosa, resultará en que su aplicación sea denegada.
Personas mayores de 12 años de edad, que deseen visitar, deberán llenar esta planilla en su totalidad. Asegúrese de firmar la planilla en el espacio indicado porque la planilla no será procesada si no está firmada.
Continúe en una hoja adjunta si es necesario.
1.Nombre del Preso:
2.DC #:
3.¿ Cuál Es su Relación con el Preso: (madre, padre, amigo, etc.)
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4. ¿ Há sido usted víctima de este preso? |
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No |
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Sí |
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Apellido: |
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5. Nombre Legal Completo: |
Primer nombre: |
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Apellido de soltera: |
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Segundo nombre: |
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Fecha de nacimiento: |
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Edad: |
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6. Información de Identidad: |
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Raza: |
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Sexo: |
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Licencia de Conducir: (16 años de edad o mayor) |
Estado: |
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Número: |
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Dirección física/Apartamento #: |
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7. Dirección Completa: |
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Ciudad: |
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Condado: |
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Estado: |
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Código postal: |
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8. Números de Teléfonos: |
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Casa (incluya el área): |
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Trabajo (incluya el área): |
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9. Empleo: |
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Lugar de empleo: |
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¿Ha sido usted empleado por el Departamento de Correcciones de La Florida?: |
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No |
Sí Aplicación Pendiente |
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¿Ha Como voluntario, ó interno, ó empleado bajo contracto ó vendedor de FDC?: |
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No |
Sí—Encierre en un círculo cual |
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Anote fechas, lugar, y nombre de la position: |
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10. Antecedentes: |
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¿Alguna vez ha sido arrestado, o ha recibido una |
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No |
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Si |
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citación criminal, o una notificación para presentarse en |
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la corte para responder a cargos criminales? |
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¿Por qué razón está usted on probación/libertad Conditional?? |
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No |
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Sí |
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¿Há ayudado alguna vez a este preso a cometer un crimen?: |
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No |
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Sí |
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¿ Há estado usted alguna vez en prisión?: |
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No |
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Sí |
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Fechas y lugaresde cada vez que ha sido puesto en prisión: |
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¿De que fué usted condenado cada vez que estuvo en prisión?: |
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¿Está usted actualmente bajo probación/o supervición bajo palabra? |
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Si es Sí, ¿cúal agencia lo está supervisando?: |
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Estado Federal |
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Condado |
Dept. de Justicia Juvenil |
Otro |
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Si su Probación/Libertad Condicional ha sido terminada indique la |
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fecha de terminación: |
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(Encierre en un círculo cada uno que sea necesario, y liste la información sobre supervisión) |
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Nombre de su oficial de probación: |
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Número de teléfono de su oficial de probación: |
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11. ¿Está Ud. Aprobado para visitar algún otro preso?: |
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No |
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Sí |
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¿Cuáles son sus nombre(s) y sus números de preso?: |
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Nombre: |
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DC#: |
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12. ¿Hán sido sus privilegios de visitas alguna vez negados, revocados ó suspendidos?: |
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No |
Sí |
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Explique por favor:
13.¿Dé donde usted conoce a este preso (Encierre en un círculo)?:
Por correo Vecindario Prisión trabajo Familia Otra razón
Yo certifico que toda la anterior información es verdadera, exacta, completa y que yo he leído todas las Reglas del Visitante localizada en la Parte 2 de este formulario y que estoy de acuerdo con obedecer estas reglas. Además, yo entiendo que el dar información falsa es un delito menor de segundo grado y podria dar lugar a la suspensión permanente de mis privilegios de visitante. Yo reconozco que se me hará un chequeo de antecedentes penales.
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Firma |
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Fecha |
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Nombre en letra de Imprenta (Apellido, Primer Nombre, Segundo Nombre) |
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Firma del padre o del guardian legal si menor de 18 |
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Fecha |
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Nombre en letra de Imprenta (Apellido, Primer Nombre, Segundo Nombre) |
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años de edad.
DC6-111A (Effective 12/14) |
AVISO A TODOS LOS VISITANTES: Lea cuidadosamente la reglas adjuntas antes de visitar. |
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POR FAVOR, NO VENGA A VISITAR HASTA QUE EL PRESO LE NOTIFIQUE A USTED QUE SU APLICACIÓN HA SIDO APROBADA Incorporated by Reference in Rule 33-601.715, F.A.C.