Name:_____________________________________ Id #:___________________
Institution Address:____________________________________________
____________________________________________
____________________________________________
____________________________________________
Optional Information (answer all, some, or none --as you see fit)
Nickname: ______________________
Date of Birth: _____________________
Height: _____________ Weight: _______________
Eye Color : ________________ Hair Color: _______________
Race: (circle) African-American Caucasion Native American Oriental Mixed
Religion: (circle) Christian Islam Judaism None Seeking Other _______________
Marital Status: (circle) Married Single(never married ) Divorced Separated Partnered
Other ________
Sexual Orientation: (circle) Straight Gay Bi-Sexual No Answer
Sentence Began: _____________________
Offenses: ____________________________________________________
Supervision Status: Incarcerated Paroled Work Release
Sentence Length: _______________________________
Parole Eligibility Date: ___________________________
Estimated Release Date: __________________________
Education: ____________________________________________________
Hobbies/Intrests: ___________________________________________________________________________
___________________________________________________________________________
Work Skills: _______________________________________________________________________________
Seeking: (Mark ALL that apply)
Open to all _____
Men Only ______
Women Only _____
Straight Only _____
Gay Only _____
Bi-Sexual ______
TV/ TS ________
Legal Help _____
Donations _____
I would like to be contacted by Christian Ministries _____
Any local mail-room restrictions at your institution ________________________________________________
_______________________________________________________________________________________
Below, write
what you would like to have appear on your web page
If you need more space, use additional sheets. Mail this, and any additional sheets along with
$19.95 in a money order, institutional check, or unused books of stamps to:
Tom Kirk, administrator,
Brothers In Prison
PMB 205
1116 W. 7th Street
Columbia, TN 38401
If you are sending any pictures or artwork, please indicate if you want them returned, Do you
wish us to also use any available pictures that may be on your DOC's website? ( Yes / No) .
Also, ( you may use / you may NOT use ) pictures that I have submitted to other websites.
As soon as your page is finished, it will be mailed to over 500 people who subscribe to my prison
pen-pals groups, and will be on the world wide web where it can be seen by anyone in the world with a
computer. Of course, there is no way we can guarantee responses, but the track record is good, and I
am advertising your page and working 10 hours a day, 7 days a week to see that you find new friends.
By signing this application, I affirm that the information I have given is as accurate as I can make it and I
agree not to hold Brothers In Prison, its owners or employees responsible in any way, for any events
present and future that may take place as a result of my submitting my ad and personal information on
this web site.
Signature_____________________________________ Date ___________________
Please keep our address handy to inform us of any change in your address or status, or to notify us if
any of your associates might be interested in having their own web page
Have a blessed day