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Indian River County Sheriff's Office <br />Corrections Division <br />Professional Visitors/Religious Volunteer Application <br />Name: Date: <br />Last First Middle <br />Alias/Nickname: Maiden: <br />Phone Number: Home: Work: Curch/Org/Agency <br />i <br />Current Address: <br />Street Apt. # <br />City State Zip <br />Date of Birth: Sex Race Ht. Wt. Eyes Hair <br />Drivers License Number: <br />SSN#: Place of Birth: <br />Purpose of Request: <br />Ever Arrested? Yes No Where? When? <br />What For? <br />Any Convictions? Yes No What For? <br />Are you related to anyone incarcerated at The Indian River County Jail: _Yes No <br />If yes what is your relationship: <br />(Please be specific about any arrest no'matter how<long ago; Information provided inay not hinder <br />your approval, but all history must be given:'Use the back side of the sheet if needed.) <br />I have answered the above in complete truth. <br />Applicants Signature <br />NOT WRITE BELOW THIS <br />Background check completed: Date: Time: <br />i <br />Background completed by: <br />i <br />Approved: Yes_ No_ Reason: <br />Administrative Lieutenant / Sergeant: Date: <br />Deliver or mail information sheet.to: Corrections. Administration;.Indian.River County Jail, 405541' <br />Avenue, Vero Beach, F1.32960 I <br />Please allow two to three weeks for background check. When background is satisfactory, you or our <br />organization will be notified. <br />i <br />