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Please read and answer all questions below. <br />Please print. Use black or blue ink. <br />Be accurate and complete. <br />All answers are subject to verification. <br /> Offender’s Information <br />Offender’s name: IDOC #: <br />Proposed Chaperone’s Personal Information <br />Print or type your full legal name: <br /> Last First Middle <br />List all other names you go by (i.e., nicknames, maiden, other married) <br />What is your relationship to the offender? <br />Do you know what crime(s) the offender committed? If yes, what is/are they? <br />List your current home address <br /> Street City State Zip <br />List your current phone numbers <br /> Home Cell Other <br />Provide your mailing address (if different from home address) <br /> Street City State Zip <br />Are you a citizen of the United States? Yes  No  If no, answer the next questions. <br />Are you a permanent resident alien who is eligible for and has applied for citizenship? Yes  No  <br />Have you obtained permission from INS to work in the United States? Yes  No  <br />Note: The following information you provide is required for verification in conducting the criminal background check: <br />Date of Birth / / Place of Birth <br /> City State <br />Social Security Number / / Driver’s license # State <br />Height Weight Hair Color Eye Color <br />Gender Male  Female  Race <br />Employer’s Name and Address <br />Drug or alcohol use? Yes  No  If yes, please list <br />Any felony offenses? Yes  No  If yes, please list <br />Any misdemeanor offenses? Yes  No  If yes, please list <br />