Attorney Agent Application PDF

604.02.01.002
Attorney Agent Application
(Last updated on 01/26/15)
IDAHO DEPARTMENT OF CORRECTION
Attorney Agent Application
Personal Information (On-line Form)
The following information is required for a criminal history check. Applicants must be at least 18 years of age. Please provide all of the information and do not leave any blanks. Use N/A if not applicable.
Inmate Name and Number you need access to:
Your Last Name: First Name: MI:
Your Maiden Name or Alias: Social Security No: DOB:
Street Address: City: State: ZIP:
Mailing Address (if different): City: State: ZIP:
Other States Lived in: Driver’s License No: State Issued:
Male Female
Email: Home: Cell: Work:
Emergency Contact: Relationship: Contact No:
Organization/business Affiliation:
Organization/business Address:
Contact Person: Phone No:
IDOC History
Are you on an inmate’s visiting list for social visits: No Yes If yes, what facility:
Inmate’s Name (list all): IDOC No: Relationship:
Do you have any relatives or friends incarcerated in Idaho (including county jails)? Yes No If yes, list each name and facility:
Have you ever been a victim of an inmate incarcerated at an IDOC facility? Yes No
Have you ever worked for the IDOC or volunteered at a correctional facility? Yes No If yes, when? Where? Organization or Affiliation?
Criminal History (Answer all questions)
Do not include any conviction record that was expunged under federal or state law or minor traffic violations. Convictions in all states must be included.
Have you been convicted of a misdemeanor within 3 years? Yes No
When, Where, Charge, Disposition (list all):
Have you ever been convicted of a felony? Yes No
When, Where, Charge, Disposition (list all):
Do you have any criminal charges currently pending? Yes No
If yes, please explain:
Are you now or have you ever been placed on probation or parole? Yes No
If yes, provide beginning and ending dates: to PO Name:
Have you ever been a member of a criminal gang? Yes No
If yes, name of criminal gang:
I grant the Idaho Department of Correction permission to run a background check and certify that the information
provided is correct and true to the best of my knowledge (box must be checked to authorize processing application).