Solicitation For Services

Name of applicant: ________________________________ Number:____________________

Address: ________________________________________

Address: ________________________________________

To: (service provider) _____________________________

(address): _______________________________________

(city, state, zip): __________________________________

I am eligible for parole on (date): _____________________

I apply for (indicate treatment, training, therapy or other service): __________________________for (identify need) ___________________________ as part of my Parole Plan.

I am (age) ________ years old. I have served a sentence for (state offense for which rehabilitation is needed) ________________________________________________.

If you are able to provide the service I need, please complete and return the enclosed Services Confirmation Form (pform7). In turn, I will submit it to the Parole Board as part of my Parole Plan.

Respectfully Submitted:

(sign) ____________________________________-