Form OP-MTV-04 F-1: Iowa Department of Corrections Visitor Application

In box 1, enter the incarcerated individual's name and the incarcerated individual's number.

In box 2, under Visitor Information, enter your legal last name, legal first name, full middle name, previous last names used and phone number.

In box 3, enter your relationship to the incarcerated individual and how long you have known the incarcerated individual.

In box 4, enter your birth date, sex, marital status, spouse's name and Social Security number.

In box 5, enter your address, city, county, state and zip code.

Do you have an American Disability Act recognized disability that requires special accommodations? YES or NO. If yes, enter what accommodation is needed.

For a service animal, circle the type, Dog or Miniature horse (send a photo of the animal), and enter what tasks the service animal is trained to perform.

In box 6, list only your children or children you have guardianship of (please provide proof) under age 18 who will be visiting with you. Anyone over age 18 must complete a separate questionnaire. For each child, enter the name, date of birth, SS#, M or F, and relationship to the incarcerated individual. If you are applying for the incarcerated individual's children, the parent/guardian must complete the application; check a box: Children can only visit with the approved parent/guardian, or Children can visit with any approved adult visitor.

In box 7, Yes or No: do you have any pending charges? Enter the State/County. If yes, enter what the charge(s) is.

In box 8, list all arrests (Adult or Juvenile), all misdemeanor convictions, all felony convictions and all deferred judgments.

In box 9, Yes or No: are you now or have you ever been incarcerated or on probation/parole? Enter the ICON/ID #, State/County and Discharge Date, and list any periods of incarceration, including jail time.

In box 10, Yes or No: have you ever been involved in the illegal use of drugs?

In box 11, Yes or No: are you currently, or have you ever been, a Department of Corrections employee or volunteer, a contractor, or private sector employer working for the Department of Corrections? If yes, list the name of the institution and the Date(s) of employment or volunteer work.

In box 12, list all names/numbers of any current or former incarcerated individuals whose visiting lists you have ever been approved/denied/suspended/removed from in the Iowa Department of Corrections. In box 13, to enhance your safety as a visitor, let the IDOC know if you have been the victim of an incarcerated individual supervised/incarcerated by the IDOC. If so, list the incarcerated individual(s) name, ID number (if known), county, charge and case number.

In box 14, Yes or No: are you a legal citizen of the United States (you will be required to show a picture ID to visit).

In box 15, by signing you give consent to initiate a background investigation with law enforcement agencies and authorize law enforcement agencies to furnish information. You also understand any falsification of the information you provided will disqualify you from visiting.

Enter the Signature and Printed Name, Date and Email Address.

It is the responsibility of the incarcerated individual to notify you of visitor application approval.

All visitors are subject to search procedures: this may include non-intrusive electronic search methods. If a visitor refuses to be searched, you will not be permitted to visit and your visiting privileges may be revised. To maintain drug-free prison zones, the non-intrusive ION SCAN method of detecting the use of, handling of or association with illegal substances (drugs) may be applied to prospective visitors.

Should the test provide a positive indication of illegal substance association or you refuse to be tested, the following minimum visiting restrictions shall apply. At the First Occurrence, visiting privileges will be suspended from the date and time of the test for the next two (2) visiting days. At the Second Occurrence, for the next seven (7) visiting days. At the Third Occurrence, for the next fifteen (15) visiting days. Future visits may be restricted to non-contact status.

At the Fourth Occurrence of a positive indication of illegal substance association, visiting privileges will be suspended from the date and time of the test for the next thirty (30) visiting days. In addition, you will be placed on non-contact visit status for one hundred and eighty (180) days from the date of the first eligible visit. If you test positive from this date forward, visiting privileges may be permanently restricted to non-contact status.

Refusal to submit to being tested will suspend visiting privileges to the facility for fifteen (15) calendar days from the time of refusal.

Return the completed application to Centralized Visiting Authority to: Mt. Pleasant Correctional Facility, Attn: Central Records, 1200 E. Washington, Mt. Pleasant, IA 52641.