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Get and Sign Request Conviction Sample Form
Registration number
.
f. Address of Potential Visitor
g. Potential Visitor’s Relationship to the inmate
h. Race of Potential Visitor
9 Black
9 White
9 Hispanic
9 Indian
9 Asian
9 Other
i. Sex of Potential Visitor
9 Male
9 Female
6. Has this person been convicted of any criminal offense? If so, please complete the appropriate
response below. An authorization to release information, signed by the person in question, is
attached.
a. Signature of Case Manager
b. Institution
c. Date
d....
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