5768

Please print clearly and mail this form to:

Jewish Prisoner Services International,

P.O. Box 85840, Seattle, WA 98145-1840

or fax to: (206) 985-0479

or by e-mail attachment to: JewishPrisonerServices@msn.com

□Chaplain □Rabbi □Volunteer Name: ____________________________________

Institution: ___________________________________________________________

Tel: (______)______-________ e-mail: ___________________________________

Postal Address: ______________________________________________________

City: _____________________ State/Province: _____ Zip/Postal Code: __________

Number of Jewish inmates at facility:_____ [Please include only those who have been verified

as having been born Jewish or properly converted.]

If High Holiday prayer books are also needed, please indicate how many:_________

Are hardcover books permitted? □ Yes □ No