APPLICATION FOR VISITING PRIVILEGES
State Form 14387 (R10 / 2-16)
DEPARTMENT OF CORRECTION
INSTRUCTIONS: 1. Please print. 2. All fields must be completed. 3. Sign the application. 4. Return this application to the offender’s counselor as indicated at the bottom of this document. 5. Do not attempt to visit until the offender notifies you that your application was approved.
6.For persons age sixteen (16) and older, submit a legible copy of photo identification. 7. For children under age sixteen (16), submit a legible copy of their birth certificate. 8. Submit a separate application for each applicant, including children.
OFFENDER INFORMATION
The above named offender has requested that you be added to his/her list of approved visitors. In order for this to be done, you must follow the directions above and you (or parent / guardian) must properly complete this application and return it to the facility to the attention of the counselor of the offender’s housing unit (do not return it to the offender). If you are approved to visit, it will be the offender’s responsibility to notify you and then send you a copy of the rules for visitation. We do not give out this information by telephone.
APPLICANT INFORMATION
Name of applicant (last, first, middle) |
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Date of birth (month, day, year) |
Gender |
Race |
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Current address (number and street, city, state, and ZIP code) - Must match identification used. |
E-mail address |
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Telephone number |
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Driver’s license number |
State of Issue |
State identification number |
State of Issue |
Other approved identification number |
Type |
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Are you related to the offender? |
If yes, how? (Must be immediate family.* ) |
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Yes 
No
*Immediate family is limited to mother, father, siblings, spouse, children, grandparents, grandchildren (including those with “step”, “half”, or adoptive relationships), and those persons with the same relationship to the offender’s spouse. Up to a maximum of twelve (12) persons will be allowed on the offender’s contact list.
Applicant under eighteen (18) years of age?
Yes 
No
Have you ever been convicted of a felony? Are you on parole / probation?
Do you have any pending charges against you?
Yes 
No
Have you ever been incarcerated in a penal facility in
any state or any country? |
Yes |
No |
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If yes, where? (Attach additional sheet, if necessary)
Why? (Attach additional sheet, if necessary)
If you answered “Yes” to any of the questions in bold, you must submit a special written request for visitation privileges to the Superintendent of the appropriate facility. If you are on parole / probation, you must also submit written approval from your Parole / Probation Officer.
Are you currently or formerly an employee of the Indiana Department |
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If yes, location |
Last date of employment (month, day, year) |
of Correction or any correctional facility in any state? |
Yes |
No |
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Are you on any other offender’s |
If yes, name of offender |
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DOC number |
Relationship |
visiting list? |
Yes |
No |
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Are you now, or have you ever been, a volunteer |
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If yes, name of facility |
Type of volunteer |
at an Indiana correctional facility? |
Yes |
No |
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ANY FALSIFICATION OF INFORMATION ON THIS APPLICATION FOR VISITATION PRIVILEGES WILL RESULT IN IMMEDIATE
SUSPENSION OF VISITATION PRIVILEGES AT ALL INDIANA DEPARTMENT OF CORRECTION FACILITIES.
By signing below, you are indicating that:
You have read, understand, and agree to abide by all rules set forth by the Department of Correction in order to visit any offender at any Department facility.
You understand that you, your property, and your vehicle, while on Department of Correction grounds, are subject to search, including frisk searches and the use of metal detectors, ion scanning equipment, and /or search dogs. You will be searched before being allowed to enter the visiting area. Refusal to submit to a search will result in you not being allowed to visit and you will be required to leave the facility immediately. Such refusal may restrict your ability to visit any offender in any Department of Correction facility.
You understand that a criminal background / warrants check will be performed for each individual applying for visiting privileges.
You understand that possession of any firearms, weapons, knives, ammunition, narcotics, controlled substances, alcoholic beverages, marijuana, tobacco or tobacco related items, or electronic devices, including cellular telephones, pagers, or other communication devices is strictly prohibited. Medication and money / currency may only be possessed in accordance with Department rules.
You understand that visits are monitored and videotaped.
You understand that placing an offender on any kind of pen-pal forum or social media will result in disciplinary action for the offender, even if the offender was unaware he/she was placed on any kind of pen-pal forum or social media.
You certify that all of the information provided on this application is true, correct, and as up-to-date as possible to the best of your knowledge and that you will notify the facility of any changes of address, telephone number, etc.
Signature of applicant |
Date (month, day, year) |
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Signature of parent / legal guardian (if under eighteen (18)) |
Date (month, day, year) |
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RETURN THIS FORM TO:
Name of facility
Attention: Counselor of _____________________________ Housing Unit
Address of facility (number and street, city, state, and ZIP code)
FOR OFFICE USE ONLY
Signature of reviewing authority (please sign legibly)