*Prison: ____________________________________________  *Prisoner I.D.#: ______________________ *First Name:_______________________ *Last Name: ___________________________________________ *Inmate’s COMPLETE Prison Mailing Address:   Building/Unit: _____________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ Home Address:_______________________________________________*Home State: ____Zip:__________ *Gender: (Circle One) M | F       *Release Date:_________________     *Date of Birth: _____________  Reason Incarcerated: __________________________________   Nick Name:__________________________ If you choose an Email Third-Party Forwarding Account, you may forward your email to up-to two (2) existing email addresses. (1)___________________________________________________________________ (2)___________________________________________________________________ Legal Statement In choosing to place a personal/legal webpage with PrisonerLife.com please understand that you and other providers of information are the publishers of the information. We are not the publishers of such information; we simply provide the space for you to place a webpage on the Internet. We make no guarantees as to the results your webpage will bring. In no event will PrisonerLife.com be responsible for any incidental, consequential, exemplary or other damages arising from or relating to your use of this service. MUST SIGN & DATE _______________________________________________________________   THINGS TO INCLUDE WITH APPLICATION (for fastest service include them all please) 1. SERVICE Personal-Ad webpage:      Up-to 250 words | Photograph*(Optional) (Print the Name & DOC# of the inmate on the back of the photo.  You MUST signed the photo to verify it is the inmate.) Email Third-Party Forwarding:      Up-to two (2) existing email addresses      you want to forward the inmate's email. *After the WebPage is published we will return the Photo to the inmate along with a full color copy of their webpage. 2. PAYMENT: Cash, check or money orders in U.S. funds only. Please Make Payable To:  PrisonerLife.com Please CIRCLE the services you are ordering. PERSONAL-AD MESSAGE BOARD EMAIL ACCOUNTS $ 34.95 $ 14.95 $  9.95 (one-time fee) when placed with either Personal/Legal Ad Third-Party Forwarding $ 19.95 $ 14.95 (one-time fee) when placed with either Personal/Legal Ad

RULES in placing an ad - PLEASE READ & FOLLOW! No names other than the prisoner may be used. No other persons' photo is allowed. You (prisoner) and you alone are in the photo only. We CAN crop the photo without damage to show only you if it is a group photo. We will not tolerate ANYONE who sends a photo of someone else claiming falsely to be the person in the photo. Print the Name & DOC# of the inmate on the back of the photo. You MUST sign the photo to verify it is the inmate. After the WebPage is published we will return the Photo to the inmate along with a full color copy of their webpage. Please notify us in writing if:  address changes | inmate is released.  We update this for FREE. Any and ALL changes to webpage must come to our office in writing by the prisoner only. We do this to protect the privacy of the webpage, from anyone else making changes the prisoner did not want! The people at the office are NOT able to correspond with prisoners on a personal basis. Legal Help Webpages may NOT include names of others, use initials only please. We reserve the right to edit, delete, reject or change wording on any webpage. NO profanity or adult content is permitted. Anyone NOT following our rules is subject to having their webpage(s) canceled WITHOUT REFUND. We set the HIGHEST standards for our web site & expect the same from the people who place their webpages with our service.