Mdoc Visiting Application Form PDF Details

Are you interested in becoming a medical specialist visitor? The mdoc Visiting Application Form is an online tool from the National Specialist Register that enables Specialists to enter their credentials so they can be considered for visiting status within the MDOC System. This short guide provides key information about the form, what it entails and how to successfully complete it. With this straightforward form, candidates have access to join teams of other experienced Specialists in various roles within healthcare settings all over Australia. Keep reading if you would like to know more!

QuestionAnswer
Form NameMdoc Visiting Application Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmichigan prison visit, application for visitation, michigan prison visitation, form mdoc

Form Preview Example

M.D.O.C. VISITING APPLICATION

CAJ-103 ■ REV. 06/11 ■ 4835-0103

Instructions For Visitors Filling Out This Application

This is an application to visit a prisoner in a Michigan correctional facility. All questions in section A and B must be answered. If a question does not apply, write Not Applicable on the line. ALL questions in Section C must be checked YES or NO. If you check YES, you must supply the requested information. All entries on this form must be clearly printed and legible. This form must be legibly signed and dated as indicated in Section D. Forms that are not legible will not be processed. Section E must be completed if applicant is a minor. Do not complete Section F. Mail the completed application to the mail room or deliver to the information desk of the facility you are requesting to visit. Do not mail the application to the prisoner. Including a self-addressed-stamped envelope when this application is returned will ensure that you receive notification of your approval or denial to visit. Without a self-addressed-stamped envelope, you will be notified only if your application is denied.

YOUR DRIVER LICENSE #

/

 

OR State ID #

/

 

 

(State)

 

(Number)

 

(State)

 

(Number)

Your Full Name (Please print)

(Last)

(First)

 

(Middle)

Your Address

 

 

 

 

 

 

 

 

 

(Street)

 

 

(Apt. #)

 

 

 

 

 

 

 

 

(City)

 

 

(State)

 

 

(Zip)

Your Date and Place of Birth

/

 

 

/

 

(City)

 

 

 

 

 

 

 

 

 

(Mo./Day/Yr.)

 

 

 

 

 

 

 

 

 

 

Prisoner Name

 

 

A

 

 

 

 

 

 

 

 

(Last)

(First)

(Middle)

 

 

Prisoner Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(State)

List ALL other names you have used (including aliases, maiden name, and names by previous marriages)

 

CHECK ONE

(Last)

 

(First)

 

(Middle)

 

MALE

(Last)

 

(First)

 

(Middle)

 

 

 

 

FEMALE

(Last)

 

(First)

 

(Middle)

 

 

 

 

 

Your relationship to the prisoner

(Are you the parent, grandparent, stepparent, spouse, child, sibling, father/mother-in-law, stepchild, grandchild, stepbrother/sister, etc.)

B

Are you a MDOC employee or provide contractual services to the MDOC?

YES

NO Work location

 

 

 

 

Are you a prisoner or a former prisoner who was incarcerated in a state or federal prison in any jurisdiction?

 

YES

NO

If so, what city & state

 

 

 

 

 

 

 

 

Date

 

 

Ever been restricted from visiting a prisoner?

YES

NO

Prisoner name & number

 

 

 

 

Date & reason for restriction

 

 

 

 

 

 

 

 

 

 

 

 

Are you currently on Parole / Probation for a felony?

YES

NO

What city & state

 

 

 

 

Have you ever been convicted of a FELONY?

YES

NO

When (mo. /yr.)

 

 

City & state

 

 

 

 

Conviction

 

 

 

 

(List all convictions • use additional paper if necessary)

C

 

I SUBMIT THAT ALL OF THE INFORMATION IS TRUE

 

 

 

 

 

 

 

 

 

 

 

 

 

D

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE OF VISITOR APPLICANT

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TO BE COMPLETED IF VISITOR IS A MINOR (unless emancipated)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I submit that above named minor is a child, stepchild, grandchild, sibling, half-sibling, or step-sibling of this prisoner. I also understand that all children

E

 

 

must be accompanied by an adult immediate family member or a legal guardian of the child.

 

 

 

 

 

 

 

 

 

 

I SUBMIT THAT ALL OF THE INFORMATION IS TRUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE OF THIS CHILD’S NON-INCARCERATED PARENT OR LEGAL GUARDIAN

 

 

 

NOTE: A COPY of the minor’s birth certificate, certificate of adoption or court order establishing paternity must be submitted with this application.

 

 

 

These copies of documents will not be returned but will be destroyed when the verification process is complete. An original or a certified true copy

 

 

 

of birth certificate, certificate of adoption, a court order establishing paternity or a valid picture ID of the minor must be presented at each visit.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STAFF USE ONLY (Type or Print Legibly)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self-addressed-stamped envelope included?

 

Yes

No

 

 

 

 

 

Facility MDOC Visiting Application processed at

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

On Visitor List

PSI reviewed

LEIN completed

 

 

Application complete

Date received

 

 

 

 

 

 

 

 

 

 

Checks completed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Reviewer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Application

APPROVED

 

DENIED

Approved / Denied by

 

 

 

Date

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Warden’s Signature (if applicant is a prisoner, former prisoner or is on parole or probation)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for denial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other comments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have been denied access to a corrections facility because of criminal history information obtained from the LEIN network,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

You may inquire about outstanding warrants by appearing at a police department and presenting identification.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

You may obtain a copy of your Michigan criminal history record at www.michigan.gov/ichat. There is a fee for this service.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Entered in Visitor Tracking

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Initials)

 

 

 

 

 

 

 

 

 

 

(Date)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: If form copied from the MDOC website, duplication and distribution by reviewing facility is required after the approval process is complete.

Distribution:

Institution Record Office File

Counselor File

Information Desk

Visitor

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1. Before anything else, while completing the mdoc visitation application, start out with the section with the subsequent blanks:

Tips to prepare michigan department of corrections visitor application step 1

2. Right after the last array of blank fields is done, go to type in the relevant details in these - Ever been restricted from visiting, YES, NO Prisoner name number, Date reason for restriction, Are you currently on Parole, YES, NO What city state, Have you ever been convicted of a, YES, NO When mo yr, City state, Conviction, List all convictions cid use, I SUBMIT THAT ALL OF THE, and SIGNATURE OF VISITOR APPLICANT.

Stage # 2 for filling out michigan department of corrections visitor application

3. This next step is going to be simple - fill in all the fields in You may obtain a copy of your, Entered in Visitor Tracking, Initials, Date, NOTE If form copied from the MDOC, Distribution, Institution Record Office File, Counselor File, Information Desk, and Visitor to finish this process.

michigan department of corrections visitor application writing process described (step 3)

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