PO Box 6905 Rutland, Vermont 05702-6905 Tel: 802-773-4029

Pen Pal Questionnaire

Most people want to know a little about you before they venture into becoming pen pals. This helps

them better pick the right person to write to. Please fill out the following questionnaire. You can fill it

out and mail it back to:

(Fill questionnaire out completely or it will not be posted.)

Reaching Beyond The Walls

PO Box 6905

Rutland, VT 05702-6905

Name: ________________________________ DOC/SID/Inmate #: _________________________

Institution Name: __________________________________________________________________

Address: ________________________________________________________________________

City: _____________________________________ State: _______ Zip Code: _________________

(Circle all that apply)

Seeking: Female / Male / Friends / Open To All / Legal

Sexual Preference: Straight / Bi-Sexual / Bi-curious / Gay / Don’t Care

Sexual Orientation: Straight / Bi-Sexual / Bi-curious / Gay / Don't Ask

Nickname: __________________________________ Age: ________ Birthday: ______________

Height: ___________ Weight: ____________ Eye Color: _____________ Hair Color: ___________

Race: ________________ Religion: __________________ Job Profession: ____________________

List all offences ( These will be verified): (1)_____________________________________________

(2) _______________________________________ (3)_________________________________

(4)________________________________________ Sentence: ____________________________

(All information about offences, release dates, parole dates, and sentence lengths will be verified)

Incarceration Date: ___________________ Conditional Release Date: ________________________

Earliest Release Date: _________________ Earliest Release Type: ___________________________

Parole Hearing Date: __________________ Parole Hearing Type: ___________________________

Parole Eligibility Date: __________________ Maximum Release Date: _________________________

Supervised Release Date and Length: __________________________ (Federal Inmates Only)

Projected Release Date: _______________________________ (WA, PA, and OR State Inmates Only)

Do you have a Cell Mate: ____________ Do you have family contact: _________________________

Referred By: __________________________________________ DOC/SID #________________

Please list the date you were arrested: ___________

Include a Photo of Yourself

(Information will not be posted without one. NO EXCEPTIONS)

(Continue on Next Page)

Hobbies: __________________________________________________________________________

_________________________________________________________________________________

Dreams and/or Wishes: ______________________________________________________________

_________________________________________________________________________________

A bit about yourself you'd like possible pen pals to know: __________________________________

_________________________________________________________________________________

We encourage you to add whatever else you'd like to add - feel free to use the back of this form as well. Be creative. Do not hesitate to add additional comments about your body, thoughts, feelings, future, past experiences or anything you would like for people to know to draw an interest.

We will add your poems, essays & thoughts to your ad.

These things WILL NOT be returned to you unless you include a SASE, POSTAGE, or EQUIVALENT.

This is what we will place on the site for your ad. We put your information on the site for people to see and we try to advertise the site so that people will find the site. PLEASE INCLUDE $5.00 FOR FIRST COPY OF AD! ALL FUTURE COPIES WITH CHANGES ARE FREE. THIS IS A ONE TIME FEE ONLY ON FIRST COPY!

WE DO NOT GUARANTEE THAT YOU WILL RECEIVE ANY MAIL!!!

We do not have a list of people waiting to write, we do not have a pool to pick from to match you up with, and we simply do not have these sorts of connections. However, we do try our best to find creative, inexpensive ways to advertise for the site. The more people outside the walls that hear about us the more chances each of you will find a pen pal. Another way you can help in this process is by treating any pen pal with the utmost respect. Word of mouth advertising is the best advertising ever. So if you hit it off with a pen pal then they will tell friends and give Reaching Beyond The Walls a good reference further boosting traffic to the site.

ALL INFORMATION SUPPLIED INCLUDING OFFENCES AND RELEASE DATES WILL BE CHECKED AND VERIFIED BEFORE BEING PLACED!!!

ANY FRAUDULENT ACTIVITY WILL BE REPORTED!!!

INCLUDE RETURN POSTAGE FOR THE RETURN OF YOUR PHOTOGRAPHS! IF NOT INCLUDED PHOTOS WILL BE DESTROYED AFTER 30 DAYS!!!