Name:______________________________________________________________

Address:____________________________________________________________

Phone:_____________________________________FAX: ____________________

E-mail:______________________________________________________________

Driver's License Number (please include state):______________________________

Social Security Number: _________________________ Date of Birth: ___________

Have you ever visited an inmate in an Illinois Department of Corrections Facility at any time?

Yes No

If yes, when and where?

Facility ____________________________________ Date _______________________

Please explain why you would like to visit in the space below:

Please return this completed form to:
Illinois Coalition to Abolish the Death Penalty, 332 S. Michigan Ave, Suite 500, Chicago, IL 60604,
or you may FAX it to (312) 427-6130. |