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Ready to go online? Fill out this form and return with payment, statement, and photo(s) to INMATE CONNECTIONS LLC 465 NE 181st, #308 Portland, Oregon 97230-6660.  We accept personal checks, cashier's checks, facility checks, and money orders made payable to “CAROLYN WHALEY.” There is a 2-week waiting period for personal checks to clear. Write or print your name and prison ID number on the front of the check or money order and mail along with the completed form below. Print neatly or type your statement on a separate sheet of paper. Not all information asked for below is required, but it is recommended that you provide it as people usually want to know. 
*Required

*YOUR FIRST NAME: ___________________________  *YOUR LAST NAME:_______________________________  *YOUR PRISONER I.D.#____________________    

*YOUR NAME AS YOU WOULD LIKE IT TO APPEAR:  __________________________________________________________________________________________

*YOUR ADDRESS_________________________________________________________________________________________________________________________

*TYPE OF FACILITY YOU ARE IN: (check one) State_____		*BIRTH DATE:___________________________    RELEASE DATE__________________   

INCARCERATED SINCE_____________________     CONVICTED OF_______________________________________________________________________________  	 

YOUR SEXUAL ORIENTATION: (check one)    Straight____  Gay____  Bisexual____    YOUR RACE_____________________________________________________	

YOUR RELIGION __________    YOUR HOME TOWN ____________________________________    YOUR HEIGHT________    YOUR WEIGHT_______ 

DO YOU WANT TO WRITE TO  (check one)    Women Only____    Men Only____    Anyone____	   WILL WRITE OVERSEAS?  (check one)    Yes____  No____    

WHAT ARE YOU SEEKING: (check all that apply)    Romance____   Friendship____   Other (specify)______________

FOR MALE INMATES WITH PERSONAL WEBPAGES, ARE YOU: (check all that apply)     Serving a Life Sentence____    On Death Row____    Gay/Bisexual____

PURPOSE OF WEBPAGE: (check one)   Personal____    Art & Business____

TYPE OF WEBPAGE: (check one) If you choose "with Brochure" option we will mail you the brochure, "How To Write A Better Pen Pal Ad," upon receipt of completed application and payment. You may send your statement after you have had a chance to review the brochure. Your application and photo will be kept on file until your statement is received. Brochure only available with purchase of web page and cannot be purchased separately.    Web Page ($49)____   Web Page w/Brochure ($59)____    

EXTRAS: (check any desired)   Front Page Placement: 4 weeks ($20)____    12 weeks ($50)____    1 year ($150)____    Pen Pal Express: 4 weeks ($100)____    12 weeks ($250)____  1 year ($750)____    Landing Page Placement 4 weeks ($300)____    12 weeks ($750)____    1 year ($2,250)____    Hit Counter ($20 per year)____    URL Submission ($20 per year)____    Linked Photo Rotation ($50)____    Extra Words____ ($10 per 50 words)    Extra Photo(s)____ ($15 per photo)	Blog Set-Up Fee ($25 and does not include cost of text and photos)_____ 

INCLUDE WITH YOUR APPLICATION:
1.	Your statement, written on separate sheet of paper.
2.	Your photo(s), if any, with your name and prison ID number written on the back and with instructions for returning if Polaroid. DO NOT PUT TAPE ON PHOTOS.
3.	Your payment.

Detach here and return completed application with payment, photo(s), and statement - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -