Name of Detainee:

_________________________________ 

A-number:

_________________________________

I hereby request authorization to participate in the Common Fare Program. I agree to comply with the program requirements. I understand that if I am observed consuming mainline foods or violating other program requirements, I may be removed from program participation and will not be eligible for immediate reinstatement. Repeated program violations may result in removal from the program for up to one year. I further understand that the same conditions for reinstatement may apply if I voluntarily withdraw from the program for any reason.

I understand that I must have a recorded religious preference in order to be eligible for the program and that I must provide a written reason for requesting to participate in the religious diet program.

Religious preference: ___________________________

Specific reason for wanting to participate in the Common Fare Religious Diet Program:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Signature of detainee: ___________________________

A-number: _____________________________________

Date: _________________________________________

Signature of chaplain: ___________________________

Date: _________________________________________

Record Copy – Detainee Detention File; Copy – Chaplaincy Office; Copy – Detainee