SOP 227.05-att-2: Application for Visitation Privilege

Application for Visitation Privilege Attachment 2
2/21/18
Page 1 of 2

Facility/Center:

Offender: GDC #:

The offender named above has request that you be approved for visitation privilege with him/her at this
institution. Prior to making the approval, we must first confirm the following information obtained from
you. Failure to provide complete and accurate information may result in denial of your visitation
privilege.

Legal Name: D.O.B. (mm /d d/y y):

Address: City:

State: Zip Code:

Occupation:

Home/Cell Telephone:

What is your relationship to the offender?

Have you ever been convicted of a crime? Yes No, if so, what is the nature of conviction(s)?
Date, county, state, and sentence received (attach additional sheet if necessary):

Are you on probation or parole? Yes No, if so, give your probation/parole officer’s name,
location and telephone number:

Are you related to any offender (s) incarcerated with Georgia Department of Corrections, other
than the one listed above? Yes No If so, give name, GDC#, institution, relation of each
offender (attach additional sheet if necessary):

Do you correspond or visit with other offenders? Yes No If so, give name, GDC#,
institution, relation of each offender (attach additional sheet if necessary):

______

Retention Schedule: Upon completion, this form shall be placed in the offender’s institutional file and shall be
maintained according to the official retention schedule for offender institutional files.

Application for Visitation Privilege Attachment 2
2/21/18
Page 2 of 2

Please check and attach appropriate documentation to verify your relationship with the listed
offender:

Notarized letter from you verifying your common law relationship

Birth Certificate Divorce Decree Other:

THIS SECTION ONLY NEEDS TO BE COMPLETED IF YOU ARE NOT EXTENDED FAMILY
(PARENT, SIBLING, CHILD, GRANDPARENT, SPOUSE, STEP-PARENT, STEP-SIBLING,
BROTHER/SISTER-IN-LAW, AUNT, UNCLE, COUSIN, HALF SIBLING, NIECE, NEPHEW, or
STEP-CHILD) OF THE OFFENDERS. PLEASE FEEL FREE TO ATTACH ADDITIONAL
SHEETS IF NEEDED.

Describe the nature of your relationship with this offender:
_______

How long have you known this offender: Prior to their incarceration? Yes No

Where and how did the relationship develop?

Explain how your relationship with the offender will assist in and contribute toward his/her
rehabilitation:

CRIMINAL/DRIVER HISTORY CONSENT (TO BE COMPLETED BY EVERYONE)

I, , hereby authorize Georgia Department of Corrections to
receive any criminal history information at any time pertaining to me which may be in the files of
any criminal justice agency on the _National Crime Information Center/Georgia Crime Information_
_Center_ (NCIC/GCIC) network.

Social Security Number Driver’s License Number

Signature Date

Signature of parent/guardian Date
(If under 18 years of age)

Retention Schedule: Upon completion, this form shall be placed in the offender’s institutional file and shall be
maintained according to the official retention schedule for offender institutional files.