NOTE: Application for personal ad must come directly from the inmate OR this release form may be signed by the inmate and sent to Friends Beyond The Wall, Inc., at the address above.

Application will not be processed without signed Release Form.

This Release Form must come directly from the inmate and from the facility where the inmate is located and is invalid if it is received from any other location.

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PLEASE TYPE OR PRINT NEATLY:

Full Name ___________________________________________________________________________________

DOC # ______________________________________________________________________________________

Facility Name ________________________________________________________________________________

Street Address _______________________________________________________________________________

City _______________________________________________ State __________ Zip Code _________________

AUTHORIZATION OF RELEASE:

I authorize Friends Beyond The Wall to publish my personal ad (ad text and personal photo) on their web site and printed materials on my behalf for the purpose of promoting my efforts to seek correspondence from the outside.

______________________________________________________________________________
Print Name Clearly

___________________________________________________________
Signature

_______________________________
DOC #

____/____/____
Date Signed

Friends Beyond The Wall, Inc.
ATTN: New Order Applications - Release Form
2600 South Road, Suite 44-244
Poughkeepsie, NY 12601-7004

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