SOP 409.04.28-att-2: Offender Alternative Entrée Program Packaged Meal Removal Form
Summary
Key Topics
- Alternative Entrée Program
- meal program discontinuation
- packaged meal removal
- food service forms
- offender meal options
- program eligibility
- 60-day exclusion
- master menu
Full Text
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Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________|
Retention Schedule: Upon completion, this form shall be kept in a local filing area in Food Service for one
(1) year in an active file and shall be kept five (5) years in an inactive file, then destroyed; a copy will
placed in the offender’s institutional file.
SOP 409.04.28
Attachment 2
12/11/24
Offender Alternative Entrée Program Packaged Meal
Removal Form
At this time, you are requesting to be removed from the Alternative Entrée Program. You
understand that once you have submitted this request you are not eligible to request to
participate inANY of the Georgia Department of Corrections Alternative Entrée Program
for a minimum of sixty (60) days. Once this request has been processed, you will be
removed from the program, and at that point, you must begin picking up the Regular
Master Menu trays.If you would like further information about the Alternative
Entrée Program, please review SOP 409.04.28.
Please list and explain the reason (s) why you would like to be removed from the
Alternative Entrée Program PACAKAGED MEAL PLAN:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Offender Name: ___________________________________
GDC#: __________________
Date Request Completed: _________________________
Date Request Received: ___________________________
Signature of Receipt: ______________________________________ (Facility Designee)
Print Name/Title: ______________________________________________||
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