16 CAR pt. 30, Appendix A
Application to Visit a Resident
Instructions to Residents: Send this form to each person (including children) you would like to have visit. Each person wishing to visit must complete all applicable sections of this form, sign it, and return it to the address below. A parent or legal guardian other than a resident must sign for children under 18.
Applicant: The “Visitation Rules and Conditions” (AR 7.24 Form 2) apply to all visitors to an Arkansas Community Correction (ACC) center. One application form must be completed for each applicant. Anyone (including a child) who wishes to visit a resident must submit this application and be approved prior to visiting. Incomplete applications will not be accepted. Visitation will be scheduled on a Saturday or Sunday during established hours. The resident will tell you the appropriate day and time for your visit.
Return the completed form to the following address:
Center Records Section
Applicant Agreement: I am applying for visitation privileges at an Arkansas Community Correction Center. I agree to abide by the “Visitation Rules and Conditions” as stated on AR 7.24, Form 2. I understand that violations may result in suspension or termination of my visitation privileges. I realize searches are necessary to assure safety, security, and orderly operations at the Center and agree to submit to a search while on ACC property. I further understand that it is the resident’s responsibility to tell me when visitation is permitted. I understand I may be detained and arrested if I attempt to bring contraband into a center or otherwise break the law. I understand I may be photographed and my photo may be stored in the ACC database for future identification. The information I provided on this form is true and I understand that if I willfully submit false information my visitation privileges will be revoked. I authorize ACC to conduct a criminal background check.
I ☐ am ☐ am not currently on Parole or Probation. My supervising Parole/Probation Officer is:
↓ RESIDENT(S) NAME & NUMBER ↓
↓ YOUR RELATIONSHIP ↓
Signature of ☐ Applicant or ☐ Guardian
Applicant’s Driver’s License/ID No.
Licensing/ID State
Print Applicant’s First Name
Middle Name
Last Name
Date
Applicant’s Birth Date
Place of Birth
Applicant’s Social Security Number
Telephone Number
Street Address
City / State
Zip Code
Sex: ☐ Female ☐ Male
Race