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Are you about to embark on a vacation, or visit family and friends out of town? If so, you'll want to complete the Visiting Questionnaire Form. This form is designed to help Customs and Border Protection (CBP) officers process your entry into the United States quickly and efficiently. The questionnaire asks for information such as your name, date of birth, citizenship, and passport number. It also asks about the purpose of your visit and where you will be staying. Completing the form in advance will save you time when you arrive at the border.

Below is the data about the file you were looking for to fill in. It will show you the amount of time you'll need to finish visiting questionnaire form, exactly what fields you need to fill in and a few further specific facts.

Question	Answer
Form Name	Visiting Questionnaire Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	94
Avg. time to fill out	19 min 22 sec
Other names	california form cdc, cdcr 106 visiting, cdcr forms, cdcr visitation

12

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STATE OF CALIFORNIA

DEPARTMENT OF CORRECTIONS

VISITING QUESTIONNAIRE

CDC 106 (Rev. 01/03)

READ CAREFULLY. Please PRINT or TYPE. The information requested will be used by officials of the California Department of Corrections (CDC) to determine whether your questionnaire will be approved or disapproved. The information provided will be maintained in a file pertaining to the inmate.

In accordance with the Privacy Act of 1974 (PL93-579), providing your Social Security number is optional. However, any omission or falsification on this questionnaire may be cause for denial of visiting. Please mail this form directly to the visiting office of the institution where the inmate is confined.

1. NAME OF INMATE YOU WANT TO VISIT (LASTFIRSTMIDDLE)INMATE’S CDC NUMBER

2. YOUR NAME (Print your name exactly as indicated on the photo identification you will he using)							SUFFIX (Jr., Sr., etc.)	HOME TELEPHONE NUMBER
								( )
3. MAIDEN NAME (If applicable)	HAVE YOU EVER USED ANOTHER NAME? IF SO, PLEASE LIST						RELATIONSHIP TO INMATE: (Spouse, Son/Daughter, other)
4. DATE OF BIRTH (Mo/Day/Yr)	GENDER (Check one)			BIRTHPLACE (City			County	State	Country)
	MALE FEMALE
5. ID NUMBER	ID TYPE (Check one) q DR1VER’S LICENSE					STATE ID	MILITARY ID
		USINS CARD				MCAS	PASSPORT
OFFICIAL USE ONLY	ISSUED BY (County		Slate			Country)		6. SOCIAL SECURITY NUMBER
EXPIRATION DATE.

7. CURRENT RESIDENCE ADDRESS: STREET ADDRESS Apt. ft (If Aplicable)						CITY		STATE	ZIP CODE

8. MAILING ADDRESS: (If different from Residence Address)						CITY		STATE	ZIP CODE

9. PREVIOUS ADDRESS WITHIN PAST TWO YEARS: Apt. ft (If Applicable)						CITY		STATE	ZIP CODE

10. ACCOMPANYING MINOR(S) (If Any): NAME, DOB, RELATIONSHIP TO INMATE
1. 2.							3.
10. Continued
4.		5.					6.
11. HAVE YOU EVER VISITED ANOTHER INMATE(S) IN A CALIFORNIA PRISON?
(Check one) YES			O NO	If YES, complete Item 11 A. Attach additional sheet(s) if more than two inmates.
(Check one) YES			O NO
11 A. INMATE NAME			CDC NUMBER		INSTITUTION WHERE YOU VISIT INMATE			RELATIONSHIP TO INMATE
I.

2.

12. HAVE YOU EVER BEEN DETAINED, ARRESTEQ,©XCONVICTED OF A CRIME? If YES, complete Item 12A. List all detentions, arrest and/or convictions. Failure to list all requested

(Check one) Q YES

NO

information may .result jn-denial of visiting. Attach additional sheet(s) if necessary.

12A. OFFENSE

APPROX. DATE

DISPOSITION: (Dismissed, Probation, Jail, Prison)

COUNTY

STATE

13. ARE YOU ON PROBATION?

ARE YOU ON PAROLE OR CIVIL

HAVE YOU BEEN INCARCERATED IN A STATE

14. ARE YOU CURRENTLY UNDER ANY TYPE OF COURT

(Check one) QygS

NO

ADDICT OUTPATIENT STATUS?

ADULT/JUVENILE CORRECTIONAL FACILITY?

IMPOSED PROGRAM? (Check one) Q YES

NO

(Check one) Q YES

NO

(Check one)

Q YES

NO

if YES, please explain on additional sheet and attach to this form.

If YES, answer 13 A.

If YES, answer 13A.

If YES, read 13B

13A. TYPE: (Court, Formal,

SUPERVISING AGENCY

NAME, ADDRESS, AND TELEPHONE NUMBER OF YOUR PROBATION/PAROLE

COUNTY

STATE

Informal, etc.)

OFFICER:

13B. If you were discharged from an institution or discharged from parole or outpatient status within the last twelve (12) months, you must have prior written approval of the Warden before visiting will be permitted. You will also need to provide a copy of your discharge paperwork.

CONrCWlED ON BACK PAGE

15.If you are under 18 years of age and are not an emancipated minor or the inmate’s legal spouse, you must have the written notarized consent of a parent or legal guardian and be accompanied by a responsible adult who is also approved to visit. The notarized written consent must be presented each time a minor visits unless prior approval has been attained form the Warden for an inmate to visit with his or her unchaperoned children.

16.VISITORS WITH DISABILITIES: If you have special requirements related to your disability (medical implants, prosthetic devices or requiring

mobility assistive devices, i.e.,. crutches, walkers, braces, wheelchairs, battery operated or custom prescribed wheelchairs, guide dog for the visually or hearing impaired, insulin kit with syringes, etc.) you will need to attach a verifying statement from your physician. Visitors with guide dogs will need to provide the dog’s certification paperwork upon visit check-in. The CDC will make every effort to provide reasonable accommodations for all qualified/eligible visitors with disabilities in keeping with the safety and security of the institution and the public. If you have any questions and/or concerns, please contact the institution where the inmate is confined.

17.The following laws relate to prison visitation:

SUBJECT TO SEARCH: Visitors entering the correctional institution, camp or facility grounds are subject to a search of their person, vehicle and property. Except as described below, visitors may leave the institution, camp, or facility grounds rather than submit to a search of their person, vehicle or property. Refusal to submit to the search will result in denial of visiting for that day.

Visitors may not elect to leave the correctional institution, camp or facility grounds rather than submit to a search when institution officials possess a court issued search warrant or cause for a search arises while the visitor is on the institution grounds and the cause for the search is believed by institutional officials to be a criminal offense.

FIREARMS AND DRUGS ON INSTITUTIONAL GROUNDS /ASSISTING INMATES TO ESCAPE: It is a felony for anyone to assist inmates to escape. Bringing firearms, deadly weapons, explosives, tear gas, drugs, drug paraphernalia, or selling drugs on prison grounds, or giving/selling inmates firearms, weapons, explosives, liquor, cocaine, or other narcotics or any kind of drugs, including marijuana, is a crime (Sections 2772, 2790,4534, 4535, 4550, 4573, 4573.5, 4573.6, 4573.8, 4573.9, 4574, 4600, California Penal Code).

GIVING LETTERS TO INMATES OR TAKING LETTERS OUT FOR INMATES BY ANYONE IS A MISDEMEANOR: (Section 4570, 4570.1, California Penal Code).

FALSE IDENTIFICATION: Anyone who falsely identifies himself/herself to gain admittance to a prison is guilty of a misdemeanor. Persons previously convicted of a felony in the State who come upon the grounds of a prison without permission of the official in charge are guilty of a felony (Section 4570.5, 4571 California Penal Code).

TRESPASSING: Entry on institution property for unauthorized purposes will be considered trespassing as provided in Section 602(j) of the California Penal Code. Refusal or failure to leave the property when requested to do so by an official will be considered trespassing as provided in Section 602(p) of the California Penal Code.

PERIOD OF EMERGENCY: In the event of an emergency situation that affects a significant portion of the inmate population at an institution, the visiting program and other program activities may be suspended during the period of emergency (Section 2601(d), California Penal Code).

GIVING OR RECEIVING GIFTS: Giving or receiving gifts to or from inmates is a misdemeanor (Section 2540, 2541, California Penal Code).

HOSTAGES: Hostages will not be recognized for bargaining purposes during attempted escapes by inmates (Section 3304, California Code of Regulations, Title 15, Division 3, Chaper 1).

18. If you are APPROVED to visit, the inmate will be notified and it is his/her responsibility to notify you.

If you are DISAPPROVED to visit, the institution will notify you by mail. You will not be allowed to visit until your application is approved.

I have read and understand the above information and agree to follow all

Federal, State and CDC rules and regulations.

VERIFICATION OF MAILING

I have mailed this Visiting Questionnaire to the visitor applicant.

VISITOR SIGNATURE

DATE

inmate;/£i6nature / cdc #

date

\|	OFFICIAL USE ONLY-TO BE COMPLETED BY INSTITUTION STAFF
APPROVED	----------------------------------------------------------------------------------Criminal History:		O NO O YES CII/FBI #	—	.

DISAPPROVED, for the following reason(s):			(If DISAPPROVED, the applicant and inmate are to be informed in writing of the disapproval.)
Omissions and/or falsifications Section(s):				Need copy of Declaration of Discharge
		Need		disposition(s)	for:
Applicant is under:	parole	formal probation		Civil Addict Outpatient supervision

Arrest record received via DOJ indicates applicant has an extensive and /or recent history of criminal activity for offenses that are particulary sensitive to the institutional security. May reapply after: (DATE:)

Applicant’s privileges to visit will be reconsidered:
	upon receipt of the above requested information		and/or	after (DATE:	)

PRINT NAME		SIGNATURE		TITLE	INSTITUTION	DATE

INMATE/V1S1TOR NOTIFIED ON (DATE)

BY WHOM

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stage 1 to filling in cdcr 106 form

You need to write down the appropriate information in the Check, on, eYES ONO, CDC, NUMBER A, INMATE, NAME, I Check, one, Q, YES A, OFFENSE COUNTY, STATE, ARE, YOU, ON, PROBATION, Check, one, Q, yg, S Q, YES If, YES, read, B ARE, YOU, CURRENTLY, UNDER, ANY, TYPE, OF, COURT OFFICER, COUNTY, and STATE space.

Finishing cdcr 106 form part 2

Make sure you provide the crucial information within the VISITOR, SIGNATURE DATE, inmate, i, nature, cdc date, ONO, OYE, SCI, I, FBI Civil, Addict, Outpatient, supervision formal, probation parole, Need, for, and, or PRINT, NAME SIGNATURE, after, DATE, TITLE and INSTITUTION section.

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