RFB - MEDICAL PRIVACY BOOTHS

San Diego County
SHERIFF'S OFFICE
VISITOR SECURITY CLEARANCE REQUEST
Legal Name: Alias or Maiden:
Date of Birth: Gender:
Social Security No.: Driver's License/ID: State:
Full Home Address:
(Street, Apt. No.) (City) (State) (Zip Code)
Personal Phone: Work Phone:
Personal Email: Work Email:
Emergency Contact: Phone:
Organization/Agency: Supervisor: Phone:
What is the purpose of your clearance? Case Management Religious Service Class Instruction Other
Please explain other:
1. Do you currently have any family members or acquaintances in Sheriff's Custody? Yes No
If yes, who? (Not disqualifying, but it must be disclosed)
2. Have you ever been convicted of a crime? Yes No
3. Have you ever been arrested or detained by Law Enforcement? Yes No
If yes, what was the result? Incarceration Probation/Parole Home Detention Diversion Fines, etc.
4. Have you ever been denied access to a Sheriff's facility? Yes No
5. Incarceration History (Check all relevant) County Jail/Local State Prison Federal Other N/A
I hereby authorize the San Diego County Sheriff's Department to conduct a background and security check on myself, as a
condition of my acceptance to enter the San Diego County Jail facilities as a visitor/volunteer/contractor. I understand that
any false statement, verbal or written, will cause my clearance request to be denied or be cause for dismissal if an
approval was made. I also understand that if any of the above information changes, I shall notify my Agency Supervisor
and the Sheriff's Department immediately.
Applicant's Signature: Date:
** *Application will not be processed without a clear copy of your valid picture identification* **
SHERIFF STAFF USE ONLY BELOW THIS LINE
Requested by: Facility/Division Contact: Phone:
This request is for: Temporary - Dates(s) Continuous (Annual) Pro-Visit (Annual)
Request entry into: EMRF GBDF LCDRF RMDF SBDF SDCJ VDF
Visit Type: Contracted Provider Volunteer Pro-Visit Religious Volunteer Clergy
Renewal: Yes No Pin#:
Investigating Deputy: ARJIS#: Date:
J-23 (Rev 09/24)