| 1. Legal Name | 2. Date of Birth | 3. Address(Including Zip Code) |
| 4. Telephone Number(Including Area Code) | 5. Race and Sex of Visitor |
| 6. Are you a U.S.Citizen?
YesNo | 6a. If yes, provide Social Security No:___
6b. If no, provide Alien Registration No:___
6c. Provide Passport No:___
6d. Provide a copy of Drivers License or Passport |
| 7. Relationship to above-named inmate | 8. Do you desire to visit him/her?
YesNo |
| 9. Did you know this person prior to his/her current incarceration? YesNo |
| 10. If the answer to #9 is yes, indicate the length of time you have known this person and where the relationship developed: |
10. If the answer to #9 is yes, indicate the length of time you have known this person and where the relationship developed.:
11. Have you ever been arrested and/or convicted of a crime? If so, state the number, date, place, and nature of the arrest/s and/or conviction/s:
12. Are you currently on probation, parole, or any other type of supervision? If so, state the name of your supervising probation/parole officer and the address and telephone no. where he/she can be contacted:
13. Do you correspond or visit with other inmates? If so, indicate the individual(s) and their location(s):
14. Driver's License No. and State of Issuance:
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize release to the Warden of: The Metropolitan Correctional Center, N.Y. any record of criminal offenses for which I have been arrested and/or convicted, and any information related to those convictions.
**FORMS RETURNED TO THE INMATE
WILL NOT BE ACCEPTED**
Applicant's Signature for Authorization to Release Information(Sign and Print Name)
(If applicant is under 18 years of age, signature of parent or guardian indicates consent of minor to visit inmate) If additional space is required, you may use the back of this form. (This form may be replicated via WP) To be filed in Inmate Central File, FOI Section 2
FOI EXEMPT/SENSITIVE BUT UNCLASSIFIED
UNCLASSIFIED
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DR-2049.ND4
MAR 2002
Visiting Application
U.S. DEPARTMENT OF JUSTICE
FEDERAL BUREAU OF PRISONS
Metropolitan Correctional Center
150 Park Row
New York, N.Y. 10007
Date:
RE:
Inmate Name and Registration number
## Dear:
I am requesting that you be included among my approved visitors. In order to establish your suitability as a visitor, it may be necessary for institution officials to send an inquiry to an appropriate law enforcement or crime information agency to ascertain whether or not placing you on my list would present a management problem for the institution, or have other possible adverse effects. The information obtained will be used to determine your acceptability as a visitor. The Bureau of Prisons' authority to request background information on proposed visitors is contained in Title 18 U.S.C. 4042.
In order for you to be considered for the privilege with me, it will be necessary for you to fill out the questionnaire and release form below and return it to the following address: Metropolitan Correctional Center
150 Park Row, New York, N.Y. 10007
Attn: Counselor Eklund, Unit 7 South
You are not required to supply the information requested. However, if you do not furnish the information, the processing of your request will be suspended, and you will receive no further consideration. If you furnish only part of the information required, the processing of your request may be significantly delayed. If the information withheld is found to be essential to the processing of your request, you will be informed, and your request will receive no further consideration unless you supply the missing information. Although no penalties are authorized if you do not supply the information requested, failure to supply such information could result in your not being considered for admittance as a visitor. The criminal penalty for making false statements is a fine of not more than $250,000 or imprisonment for not more than five years or both (See 18 U.S.C. 101).
Sincerely, (Inmate Signature)
*Forms Returned To The Inmate WILL NOT BE ACCEPTED*
| 1. Legal Name | 2. Date of Birth | 3. Address(Including Zip Code) |
| 4. Telephone Number(Including Area Code) | 5. Race and Sex of Visitor |
| 6.Are you a U.S.Citizen?
YesNo | 6a.If yes,provide Social Security No:___
6b.If no,provide Alien Registration No:___
6c.Provide Passport No:___
6d.Provide a copy of Drivers License or Passport |
| 7.Relationship to above-named inmate | 8.Do you desire to visit him/her?
YesNo |
| 9.Did you know this person prior to his/her current incarceration? YesNo |
| 10.If the answer to #9 is yes,indicate the length of time you have known this person and where the relationship developed.: |
11. Have you ever been arrested and/or convicted of a crime? If so, state the number, date, place, and nature of the arrest/s and/or conviction/s:
12. Are you currently on probation, parole, or any other type of supervision? If so, state the name of your supervising probation/parole officer and the address and telephone no. where he/she can be contacted:
13. Do you correspond or visit with other inmates? If so, indicate the individual(s) and their location(s):
14. Driver’s License No. and State of Issuance:
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize release to the Warden of: The Metropolitan Correctional Center, N.Y. any record of criminal offenses for which I have been arrested and/or convicted, and any information related to those convictions.
**FORMS RETURNED TO THE INMATE
WILL NOT BE ACCEPTED**
Applicant's Signature for Authorization to Release Information(Sign and Print Name)
(If applicant is under 18 years of age, signature of parent or guardian indicates consent of minor to visit inmate) If additional space is required, you may use the back of this form. (This form may be replicated via WP) To be filed in Inmate Central File, FOI Section 2
FOI EXEMPT/SENSITIVE BUT UNCLASSIFIED
2020-015777-1
Hcm 3 11000~
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UNCLASSIFIED
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