BP-A0291 FURLOUGH APPLICATION - APPROVAL AND RECORD CDFRM
NOV 12
U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS
Inmate's Name Register No. Institution(address and phone number)
APPLICATION
Purpose of Visit Sentry Assignment
FURL ____________
Date/Time of Departure Date/Time of Return
Furlough Address (include name of responsible party if applicable):
Telephone No. (Including Area Code):
Point of Contact for Method Transportation
Emergency
of

Detainer/Pending
Charges
Verified by (CSM Staff)
NOTE TO APPLICANT: You are reminded that should any unusual circumstances arise during the period of
your visit, you should notify the institution immediately at telephone:
UNDERSTANDING
I understand that if approved, I am authorized to be only in the area of the destination shown above
and at ordinary stopovers or points on a direct route to or from that destination. I understand that
my furlough only extends the limits of my confinement and that I remain in the custody of the Attorney
General of the United States. If I fail to remain within the extended limits of this confinement, it
shall be deemed as escape from the custody of the Attorney General, punishable as provided in Section
751 of Title 18, United States Code. I understand that I may be thoroughly searched upon my return to
the institution and that I will be held responsible for any item of contraband or illicit material that
is found. I have read or had read to me, and I understand that the foregoing conditions govern my
furlough, and will abide by them. I have read or had read to me, and I understand the CONDITIONS OF
FURLOUGH as set forth on the reverse of this form.
Witness Signature of Applicant
Title Date Signed
ADMINISTRATIVE ACTION
Information Verified by Title
Name Of USPO Notified Date of Notification
Does USPO Have Any Objections to Furlough? (If so, explain)
APPROVAL
Approval for the above named Inmate to leave the
Institution on a furlough as outlined is hereby
granted in accordance with P.L. 93-209 and the BOP
Furlough Program Statement. The period of
furlough is
from to
As CMC, I have reviewed the Request for Activity
Clearance (404) and the SENTRY CIM Clearance and
Separatee Data and I recommend the inmate be
approved to participate in this furlough.
G Yes G No Signature of CMC
Chief Executive Officer (Name & Date) - Approval and signature certifies CIMS Clearance
~ Approval ~ Disappr
oval
Reason(s) for disapproval:
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Date/Time Released: Date/Time Returned:
Travel Schedule:
Inmate's Photo
Conditions of Furlough
(a) An inmate who violates the conditions of a furlough may be considered an escapee under 18
U.S.C. § 4082 or 18 U.S.C. § 751, and may be subject to criminal prosecution and institution
disciplinary action.
(b) A furlough will only be approved if an inmate agrees to the following conditions and
understands that, while on furlough, he/she:
(1) Remains in the legal custody of the U.S. Attorney General, in service of a term of
imprisonment;
(2) Is subject to prosecution for escape if he/she fails to return to the institution at
the designated time;
(3) Is subject to institution disciplinary action, arrest, and criminal prosecution for
violating any conditions(s) of the furlough;
(4) May be thoroughly searched and given a urinalysis, breathalyzer, and other comparable
test, during the furlough or upon return to the institution, and must pre-authorize the
cost of such test(s) if the inmate or family members are paying the other costs of the
furlough. The inmate must pre-authorize all testing fee(s) to be withdrawn directly
from his/her inmate deposit fund account;
(5) Must contact the institution (or United States Probation Officer) in the event of
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Special Instructions:
It has been determined that consumption of poppy seeds may cause a positive drug test
which may result in disciplinary action. As a condition of my participation in
community programs, I will not consume any poppy seeds or items containing poppy seeds.
(Note: Additional conditions may be added to Special Instructions as
warranted).
(c) While on furlough, the inmate must not:
(1) Violate the laws of any jurisdiction (federal, state, or local);
(2) Leave the area of his/her furlough without permission, except for traveling to the
furlough destination, and returning to the institution;
(3) Purchase, sell, possess, use, consume, or administer any narcotic drugs, marijuana,
alcohol, or intoxicants in any form, or frequent any place where such articles are
unlawfully sold, dispensed, used, or given away;
(4) Use medication that is not prescribed and given to the inmate by the institution
medical department or a licensed physician;
(5) Have any medical/dental/surgical/psychiatric treatment without staff's written
permission, unless there is an emergency. Upon return to the institution, the inmate
must notify institution staff if he/she received any prescribed medication or treatment
in the community for an emergency;
(6) Possess any firearm or other dangerous weapon;
(7) Get married, sign any legal papers, contracts, loan applications, or conduct any
business without staff's written permission
(8) Associate with persons having a criminal record or with persons who the inmate knows to
be engaged in illegal activities without staff's written permission;
(9) Drive a motor vehicle without staff's written permission, which can only be obtained if
the inmate has proof of a currently valid drivers license and proof of appropriate
insurance; or
(10) Return from furlough with anything the inmate did not take out with him/her (for
example, clothing, jewelry, or books).
I have read, or had read to me, and I understand the above conditions concerning my furlough and agree to abide
by them.
Inmate's Signature: Reg. No.: Date:
Signature/Printed Name of Staff Witness:
Record Copy - Inmate Central File; Copy - Control Center, Chief Correctional Services Supervisor, Correctional
Systems Department, Inmate Use on Furlough
Conditions of Furlough - Inmate's Copy
1. I will not violate the laws of any jurisdiction (federal, state, or local). I understand that I am
subject to prosecution for escape if I fail to return to the institution at the designated time.
2. I will not leave the area of my furlough without permission, with exception of traveling to the furlough
destination, and returning to the institution.
3. While on furlough status, I understand that I remain in the custody of the U.S. Attorney General. I
agree to conduct myself in a manner not to bring discredit to myself or to the Bureau of Prisons. I
understand that I am subject to arrest and/or institution disciplinary action for violating any
condition(s) of my furlough.
4. I will not purchase, possess, use, consume, or administer any narcotic drugs, marijuana, intoxicants in
any form, nor will I frequent any place where such articles are unlawfully sold, dispensed, used, or
given away.
5. I will not use any medication that is not prescribed and given to me by the institution medical
department for use or prescribed by a licensed physician while I am on furlough. I will not have any
medical/dental/surgical/psychiatric treatment without the written permission of staff, except where an
emergency arises and necessitates such treatment. I will notify institution staff of any prescribed
medication or treatment received in the community upon my return to the institution.
6. I will not have in my possession any firearm or dangerous weapon.
7. I will not get married, sign any legal papers, contracts, loan applications, or conduct any business
without the written permission of staff.
8. I will not associate with persons having a criminal record or with those persons who I know are engaged
in illegal occupations.
9. I agree to contact the institution (or United States Probation Officer) in the event of arrest, or any
other serious difficulty or illness.
10. I will not drive a motor vehicle without the written permission of staff. I understand that I must have
a valid driver's license and sufficient insurance to meet any applicable financial responsibility laws.
11. I will not return from furlough with any article I did not take out with me (for example, clothing,
jewelry, or books). I understand that I may be thoroughly searched and given a urinalysis and/or
breathalyzer and/or other comparable tests upon my return to the institution. I understand that I will
be held accountable for the results of the search and test(s).
12. It has been determined that consumption of poppy seeds may cause a positive drug test which may result in
disciplinary action. As a condition of my participation in community programs, I will not consume any
poppy seeds or items containing poppy seeds.
13. Special Instructions:
PDF Prescribed by PS 5280 Replaces BP-291 of SEPT 1999
FILE IN SECTION 5 UNLESS APPROPRIATE FOR PRIVACY FOLDER SECTION 5
Spanish: Conditions of Furlough Template Copy
This is a translation of an English-language document provided as a courtesy
to those not fluent in English. If differences or any misunderstandings
occur, the document of record shall be the related English-language document.
Esta es una traducción de un documento escrito en inglés, distribuido como
una cortesía a las personas que no pueden leer inglés. Si resulta alguna
diferencia o algún malentendido con esta traducción, el único documento
reconocido será la versión en inglés.
Condiciones de Permiso de Salida Temporera - Copia del Reo
1. No violaré leyes de ninguna jurisdicción (federal, estatal, o local). Entiendo que estoy sujeto
al juicio por fuga si no vuelvo a la institución en la fecha designada.
2. No dejaré el área designada por mi permiso de salida temporera sin autorizaci ón, con excepción
al viaje hacia el area designada por el permiso de salida temporera, y el regreso a la institución.
3. Mientras esté en estado de permiso de salida temporera, entiendo que permanezco en la custodia
del General de Fiscal de EE.UU.. Acuerdo a conducirme en una manera que no desacredite a mi persona ni
a la Agencia Federal de Prisiones. Entiendo que estoy sujeto a arresto y/o accion disciplinaria de la
institución por violación de cualquier condición de mi permiso de salida temporera.
4. No compraré, poseeré, usaré, consumiré, o administraré ninguna droga narcótica, marihuana,
estupefacientes en cualquier forma, ni tampoco frecuentaré cualquier lugar donde tales artículos son
ilegalmente vendidos, dispensados, usados, o regalados.
5. No usa ninguna medicación que no sea recetada y dada por el departamento médico de la
institución para mi uso o recetada por un médico autorizado mientras estoy bajo permiso de salida
temporera. No tendré ningún tratamiento médico/dental/quirúrgico/psiquiátrico sin el permiso escrito
del personal, excepto en caso de emergencia que requiera tal tratamiento. Notificaré al personal de la
institución sobre cualquier medicación recetada o tratamiento recibido en la comunidad al regresar a
la institución.
6. No tendré en mi posesión ninguna arma de fuego o arma peligrosa.
7. No contraeré matrimonio, ni firmaré cualquier papel legal, contratos, solicitudes de préstamo
o conduciré cualquier negocio sin el permiso escrito del personal.
8. No me asociaré con personas con antecedentes criminales o con aquellas personas quienes conozco
estar envueltos en ocupaciones ilegales.
9. Acuerdo ponerme en contacto con la institución (u Oficial de la Oficina Federal de Libertad
Supervisada) en caso de arresto, o cualquier otra dificultad seria o enfermedad.
10. No conduciré un automóvil sin el permiso escrito del personal. Entiendo que debo tener una
licencia de conducir válida y suficiente seguro automovilístico para satisfacer cualquier ley de
responsabilidad financiera aplicable.
11. No volveré de salida temporera con ningún artículo con el cual no haya salido (por ejemplo,
ropa}, joyas, o libros). Entiendo que puedo ser registrado a fondo y administrado un análysis de orina
y/o alcohómetro y/u otras pruebas comparables al regresar a la institución. Entiendo que seré
responsable por los resultados del registro y prueba(s).
12. Ha sido determinado que el consumo de semillas de amapola puede causar un resultado positivo en
una prueba de drogas , lo cual puede resultar en acción disciplinaria. Como condición de mi
participación en programas comunitarios, no consumiré ninguna semilla de amapola o artículos que
contengan semillas de amapola.
13. Instrucciones Especiales:
Yo he leído, o se me leyeron, y entiendo las condiciones anteriormente dichas acerca de mi permiso
de salida temporera y acuerdo a cumplir con ellas.
Firma del Reo: Número de Registro: Fecha:
Firma / Nombre Impreso de Testigo del Personal:
FILE IN SECTION 5 UNLESS APPROPRIATE FOR PRIVACY FOLDER SECTION 5