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VISITOR REGISTRATION FORM
INMATE: ____________________________________________ MDOC #: ______________________
VISITOR’S NAME: _____________________________________ DATE OF BIRTH: _______________
VISITOR’S ADDRESS: ___________________________________ PHONE #: ___________________
CITY, STATE, ZIP CODE: ________________________________________________________
VISITOR’S SS# _______- ____- ________ RACE: __________ SEX: M _______ F ________
The above named inmate has requested you as a possible addition to his visiting list, with the hope that
this will aid in maintaining their family ties. All information requested must be provided in order to
place you on this offender’s visitation list.
What is your relationship to this offender? ______________________________________
Have you ever been convicted of a felony? Yes_____ No_____
Have you ever been incarcerated? Yes_____ No_____ If yes, give dates: ________________________
Location and D.O.C. Number: ___________________________________________________________
If you are a female, and have been married, what is your maiden name? _________________________
If you have children with this inmate as the father, please state their full names and ages:
Are you or have you ever been on probation or parole? If yes, give dates.
From_________ To ___________
Have you ever or are you currently employed with the Mississippi Department of Corrections, including
contractual services (i.e. food services, medical services)? Yes_____ No_____ If yes, when_________,
Are you related to any other inmate in this facility or any correctional facility in Mississippi? Yes_______
No_____ If yes, give name, MDOC number, location and relationship: ___________________________
Are you presently visiting any other inmate in this or any correctional facility in Mississippi?
Offender Name ______________________ MDOC # _________ Name of Facility__________________
NOTE! ALL VISITORS MUST BE OVER THE AGE OF EIGHTEEN
(18) YEARS OF AGE TO VISIT WITH AN INMATE UNLESS
ACCOMPANIED BY A PARENT OR GUARDIAN.
Return Form to: KNRCF
300 Industrial Park Road
DeKalb, MS 39328