1002-3
3/22/13
ARIZONA DEPARTMENT OF CORRECTIONS
Offenders under supervision of the Arizona Department of Corrections shall be required to agree to the Conditions
of Supervision and release as follows:
Yes No
Yes No
Yes No
By signing below, I agree to comply with the above listed conditions. Failure to sign will result in my not being released at this
time.
Offender Name
(Last, First M.I.)
Witness Name
(Last, First, MI.) (Please print)
Offender Signature
Witness Signature
ADC Number
Date
Date
Upon release from custody. I will contact my Supervising Officer, CO III or Officer of the Day by personal visit within one (1)
working day unless otherwise directed.
I will maintain contact with my Supervising Officer and follow all directives I am given, either verbal or written.
I will obtain approval from my Supervising Officer before changing my residence or mailing address. I will secure a written
travel permit/waiver of extradition from my Supervising Officer before leaving the State of Arizona. I hereby waive extradition if
I should be arrested in any other state and will not resist being returned to the State of Arizona.
I will seek, obtain and maintain employment, if legally permitted to do so. I understand I will attend school, approved programs
or treatment as directed by my Supervising Officer and will participate in school or the approved programs or treatment as
directed.
I will obey all city, county, state, federal and tribal laws. I will inform my Supervising Officer, within (1) working day, of any
contact that I have had with any law enforcement agency. I will not engage in assaultive, violent or threatening activities of any
sort.
3.
4.
5.
6.
I will not consume or use any form of alcohol, or any substance containing alcohol, at any time. I will not possess, use,
distribute, sell, manufacture or have under my control any illegal drugs, controlled substances, narcotics, toxic vapors (as
inhalants) or prescription drugs not prescribed to me by a licensed Physician. I will submit blood, urine or Breathalyzer samples
when requested by any Supervising Officer.
At no time will I own, possess, transport, use or have under my control any electronic stun or control device, firearms, deadly or
prohibited weapons, explosives or ammunition as defined in A.R.S 13-3101.
7.
8.
9.
10.
2.
1.
12.
13.
14.
15.
I will not have any contact with any victims; I will not knowingly associate with any person engaged in criminal activity,
codefendants, or anyone under the jurisdiction of ADC or Probation or in the custody of any law enforcement agency without
prior authorization or permission from my Supervising Officer.
I will submit to a search of my person, automobile or place of residence at any time, with or without a warrant by any
Community Corrections Officer or Supervisor.
I will not enter into any agreement to act as an informant or special agent for any law enforcement agency without the written
consent of my Supervising Officer.
Special Conditions apply, Form #1002-3SPCL:
Special Conditions apply, Form #1002-3SO:
If applicable, I will not remain in or return to the United States illegally if I am deported or processed through voluntary departure.
Should I illegally return to the United States, I hereby waive extradition from any jurisdiction in the United States and shall not
contest any effort by any jurisdiction to return me to the State of Arizona.
11.
If applicable, I will pay fees, fines and/or restitution as determined by the Board of Executive Clemency, the sentencing court or
state statues.
Special Conditions apply, Form #1002-3GPS:
Release Type
CSBD
ERC
SED
Conditions of Supervision and Release
