SHELBY COUNTY DIVISION OF CORRECTIONS INMATE VISITATION APPLICATION
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: