1. FULL NAME ______________________________________ D.O.B. __ / __ / ___

2. AIS N0. _______________________________ DORM/BED/CELL NO. ________

3. LENGTH OF SENTENCE: _____________________________________________

4. COUNTY OF CONVICTION: ___________________________________________

5. DID YOU LIVE IN THE COUNTY OF CONVICTION? Y N IF N0, PLEASE EXPLAIN.

____________________________________________________________________

6. OFFENSE FOR WHICH YOU WERE CHARGED ______________________________

7. OFFENSE FOR WHICH YOU WERE CONVICTED ____________________________

8. DATE OF CONVICTION _______________________________________________

9. ARE YOU MARRIED, SINGLE, DIVORCED, ETC? M S D Other ___________________

10. DO YOU HAVE CHILDREN? Yes No IF YES, HOW MANY? _____________________

11. IS ANY MEMBER OF YOUR FAMILY A REGISTERED VOTER? _________________

12. DO YOU COMMUNICATE ON A REGULAR BASIS WITH YOUR FAMILY MEMBERS? _____________________________________________________________________

13. WHAT IS YOUR JOB ASSIGNMENT AT THIS INSTITUTION? ________________

14. DO YOU HAVE A TRADE OR SKILL? Yes No

IF YES, NAME WHAT IT IS/THEY ARE: _____________________________________

15. LIST ANY SPECIAL TALENT(S) YOU POSSESS: _____________________________

16. DO YOU HAVE A: GED, HS DIPLOMA, ASSOC DEGREE, COLLEGE DEGREE, 
OTHER, (PLEASE LIST) ___________________________________________________

IF NONE OF THE ABOVE, LIST THE HIGHEST GRADE COMPLETED ________________

17. HOW OFTEN DO YOU RECEIVE VISITS FROM FAMILY OR FRIENDS? __________

18. WHAT DO YOU EXPECT TO RECEIVE BY PARTICIPATING IN THE LIFERS GROUP? _____________________________________________________________________

19. WHAT CAN YOU CONTRIBUTE TO THE LIFERS GROUP?______________________

20. IS THERE A MEMBER OF YOUR FAMILY OR A FRIEND WHO IS WILLING TO ASSIST YOU IN THE LIFERS GROUP ACTIVITIES? ___________________________________

21. IF ACCEPTED, WHAT COMMITTEE WOULD YOU LIKE TO WORK WITH?

(The list below is not a complete list of the committees offered)

A. Legal Research

B. News Letter

C. Public Relations

D. Community Outreach

E. Family Support

F. Youth Program on Violence

G. Nonviolence Workshop

H. Personal Growth

I. Productive Life After Prison

J. How to do Time Effectively

22. BRIEFLY IN A FEW LINES TELL US SOMETHING ABOUT YOURSELF OR GIVE A BRIEF SUMMARY OF YOUR LIFE: ____________________________________________________

__________________________________________________________________________

************************Do Not Write Below this line**************************

APPROVED ? 

DENIED ?

__________________
CHAIRMAN

_________________
VICE CHAIRMAN

__________________
SECRETARY

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