SOP 106.05-att-1: Request to Designate_Change Religious Preference Form

SOP 106.05

Attachment 1

11/6/17

# Request to Designate/Change Religious Preference Form

__________________________________________

Facility

Offender Name: ________________________ ID#: _________________ Date: ____________

Nature of Request:

Designate Religious Preference

Designated Religious Preference: _________________________________________________________________

Change Religious Preference

Prior Designated Religious Preference: ____________________________________________________________

Requested Change to Religious Preference: _________________________________________________________

_____________________________________
Offender’s Signature

______________________________________________ Approved/Disapproved (Circle one)
Facility Chaplain (Signature/Date)

______________________________________________ Approved/Disapproved (Circle one)
Counselor (if Chaplain Unavailable) (Signature/Date)

Comments:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Retention Schedule: Upon completion, this attachment shall be maintained in the offender’s institutional file
according to the retention schedule for state government records.

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RECEIPT FOR REQUEST TO DESIGNATE/CHANGE RELIGIOUS PREFERENCE REQUEST:

OFFENDER'S NAME_________________________________ GDC I.D. #: _________________________

I ACKNOWLEDGE RECEIPT OF THE SPECIAL REQUEST FORM FROM THE ABOVE OFFENDER.
DATE: ______/______/______ CHAPLAIN/COUNSELOR'S SIGNATURE ___________________________