SOP_NUMBER: 106.05-att-1
TITLE: Request to Designate_Change Religious Preference Form
REFERENCE_CODE: VA01-0005
WORD_COUNT: 167
URL: https://gps.press/sop-data/106.05-att-1/

ATTACHMENTS:
  1. Request to Designate_Change Religious Preference Form
     URL: https://gps.press/sop-data/106.05-att-1/

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FULL TEXT:
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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 ___________________________