Cdcr Confidential File Form

STATE OF CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION CONFIDENTIAL PHONE CALL REQUEST CDCR 106-A 02/08 READ CAREFULLY. Please PRINT or TYPE. The information requested will be used by officials of the California Department of Corrections and Rehabilitation CDCR to determine whether your questionnaire will be approved or disapproved. The information provided will be maintained in a file pertaining to the inmate. Please PRINT or TYPE. The information requested will be used by officials of the California Department of Corrections and Rehabilitation CDCR to determine whether your questionnaire will be approved or disapproved. The information provided will be maintained in a file pertaining to the inmate. In accordance with the Privacy Act of 1974 PL93-579 providing your Social Security number is optional. However any omission or falsification on this questionnaire may be cause for denial of the confidential phone call. Please mail this form directly to the Litigation Coordinator s office of the institution where the inmate is confined. 1. STATE OF CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION CONFIDENTIAL PHONE CALL REQUEST CDCR 106-A 02/08 READ CAREFULLY. Please PRINT or TYPE* The information requested will be used by officials of the California Department of Corrections and Rehabilitation CDCR to determine whether your questionnaire will be approved or disapproved* The information provided will be maintained in a file pertaining to the inmate. In accordance with the Privacy Act of 1974 PL93-579 providing your Social Security number is optional* However any omission or falsification on this questionnaire may be cause for denial of the confidential phone call* Please mail this form directly to the Litigation Coordinator s office of the institution where the inmate is confined* 1. NAME OF INMATE YOU WANT TO CALL LAST FIRST MIDDLE INMATE S CDC NUMBER 2. YOUR NAME Print your name exactly as indicated on the photo identification you will be using SUFFIX Jr. Sr. etc* OFFICE TELEPHONE NUMBER 3. MAIDEN NAME If applicable HAVE YOU EVER USED ANOTHER NAME IF SO PLEASE LIST FAX NUMBER 4. DATE OF BIRTH Mo/Day/Yr AGE GENDER Check one MALE 5. ID NUMBER BIRTHPLACE City ID TYPE BAR / P. I. NUMBER ISSUED BY County 7. CURRENT MAILING ADDRESS STREET ADDRESS State BAR STANDING Check one Verified Apt. If Applicable Unverified 6. SOCIAL SECURITY NUMBER Optional CITY STATE ZIP CODE If YES complete Item 9A. List all detentions arrest and convictions. Failure to list all requested information may result in denial of your confidential phone call* Attach additional sheet s if necessary. 8. HAVE YOU EVER BEEN CONVICTED OF A FELONY Yes No 9. OFFENSE Check one FEMALE DRIVER S LICENSE OFFICIAL USE ONLY EXPIRATION DATE DISPOSITION Dismissed Probation Jail Prison APPROX. DATE COUNTY Attorney or Attorney s representative must provide a written request on official letterhead indicating the purpose for the confidential phone call* Signature of Requestor Date APPROVED Signature of CLETS Operator Signature of Litigation Coordinator If DISAPPROVED the applicant is to be informed in writing of the disapproval* REASON FOR DISAPPROVAL PRINT NAME SIGNATURE TITLE INSTITUTION DATE.