Inmate Name: _____________________________________ R&I #: ______________________
Read Carefully: All questions must be answered. Any omissions or falsifications will be considered sufficient reason for disapproval for visitation. Return this form to the Operations Department at Shelby County Division of Corrections, 1045 Mullins Station Road, Memphis, Tennessee – 38134. The application will become apart of the inmate’s institutional record under the provisions of T.C.A. 4-3-603, 4-3-606, and 4-6-140. It will be considered as public record available for review by the general public, subject to the procedures established in the above-cited statues.
Name
(Fill in form online where indicated by shading & print out when completed)
Race
(Place a Checkmark in the Appropriate Box)
Relationship To Inmate
(Place a Checkmark in the Appropriate Box)
First: Middle: Last:
Address
Street: City: State: Zip:
Asian or Pacific Islander Black Hispanic American Indian Alaskan Native White
Mother Father Brother
Telephone Number Home: ( )
Date of Birth Age: Month: Day: Year:
Sex Male: ______ Female: _______
Employer
Height / Weight Feet: Inches: Weight:
Employer: Address: Telephone Number:
Sister Wife Husband Child Grandmother Grandfather Cousin Uncle Aunt Niece Nephew Foster Child Foster Parent Step Father
Social Security No. Step Mother
Step Sister Step Brother Mother-in-law
Driver’s License or State ID Number State: ____________ Number:_____________________
Father-in-law Brother-in-law Sister-in-law
Vehicle Information
Make: Model: License Tag Number: _____________ State: _________
Are you currently visiting another inmate at the Division of Corrections? ______________ If yes, what is his/her name: _____________________________________ Number: _____________ Relationship: ________________ Have you ever been convicted of a felony? _____________________ If yes, please list offense(s), date, location, and disposition of sentence. Please include your State Number or R& I number: _____________________________________________________________________________________________ _____________________________________________________________________________________________ Have your visitation privileges ever been suspended from the Division of Corrections for any reason: ___________ If yes, please explain: