302.100A (1/2020)
Please Print
Offender: __________________________________________________________________ OID# __________________
Last
First
Middle
Visitor: ________________________________________________________________________________________________
Last
First
Full Middle
Maiden Name/All Aliases
DOB: ______________________ Gender: _____
Address: __________________________________________________________________ ____________________________
City: ______________________________________ State: ______ Zip Code: ______
Phone Number: (______)_________________ Relationship to Offender (e.g., Mother, Friend): _______________
***If you answer yes to any question below, please explain in COMMENTS
No Yes
No Yes
No Yes
No Yes
Yes
No Yes
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1. Have you ever been a resource/volunteer/employee at any MN correctional facility?
2. Do you have ANY pending charges against you?
3. Do you have any Non-Contact Orders or OFP’s with anyone incarcerated in the DOC?
4. Are you on another offender’s visiting list at any MN correctional facility?
5. Have you ever been released from a state or federal correctional facility?
6. Are you on probation, parole or release status?
(If yes, you must include your agent’s name and/or county, and phone number below)
Phone# (_____)__________
Signature: _______________________________________________________________ Date: ______________________
THE ABOVE INFORMATION IS TRUE AND CORRECT. I UNDERSTAND THAT PROVIDING
FALSE INFORMATION ON THIS FORM IS GROUNDS FOR DENYING VISITING PRIVILEGES.
If application is not legible, it will be denied.
FOR OFFICE USE ONLY
Received__________ Criminal History Check Completed on__________
Approved__________ Denied___________ Staff Initials___________
MINNESOTA DEPARTMENT OF CORRECTIONS
Visiting Privilege Application Form
Anyone under 18 years of age must be escorted by a parent, legal guardian or an authorized escort
A copy of each minor's state/county birth certificate must be sent with the visiting application. Birth certificates will not be
accepted at the time of visit. The hospital's Heirloom Birth Certificate, or Crib Card, is not an official document and will not
be accepted. If an adult other than the parent or legal guardian escorts a minor, a notarized Minor Escort Form signed by
the child's custodial parent/guardian must accompany the birth certificate or guardianship papers.
Full name and date of birth of all minors under age 18 that I will escort:
For Office Use Only
Facility: ______________
Victim: _______________
No
___
_____________________________________________________________________________________________________
________________________________________________________________________________________________________
Type of ID - Enter ID Number: An expired/canceled Driver’s License does not qualify as a valid ID for visiting purposes.
Driver’s license or ID Card from state/territory of residence #:___________________________________________
***Photocopy of ID or Driver’s License must be attached and
match address on application or application will be denied.
Valid military ID #:____________________ Matricula Consular ID #:________________________
Minnesota Tribal ID-Tribe:______________________ Passport #:___________________________
Apt./Unit
***When/Where/Who?
Agent’s Printed Name: __
___________________________________________________
(If no agent, enter county name. If no information is entered, application will be denied.)
***COMMENTS:
