Set Free AfterCare Ministry, Inc.
P. O. Box 108
2659 Freedom Pkwy.
Cumming, GA. 30041
INMATE INFORMATION FORM
(Inmate)

In order to better assist you and send a prompt reply to your request for assistance, we ask that you complete this form and return it to our office. We have included a form for your counselor and institution Chaplain to complete and return to our office. Please give your permission to release information. Completion of this form does not guarantee a resident plan with Set Free After-Care Ministry, Inc.

EF._________________

Name: _______________________________________________________ I.D.__________________

Age _________ Date of Birth: ________________ Race: __________ SSN: _____________________

Marital Status: Single ( ) Married ( ) Divorced ( ) Widowed ( )

Institution Address: __________________________________________________________________

Nature of Offense(s): _________________________________________________________________

Date of Sentence(s): _________________________________________________________________

Tentative Parole Month: __________________ Maximum Release Date: _______________________

Name of Nearest Relative: ______________________________Relationship: ___________________

Address: ___________________________________________________ Phone: ________________

Counselor: ______________________________Chaplain: ___________________________________

Education: _____________________________________________________________________________

Work Experience: ___________________________________________________________________

__________________________________________________________________________________

Trade(s): __________________________________________________________________________

Skill(s): ___________________________________________________________________________

Are you HIV Positive? ( ) Yes ( ) No

List any Disabilities: _________________________________________________________________
Permission to release information ( ) Yes ( ) No.

Signature: ___________________________________ Date: ____________________


Thank You,
Tom Allanson, Director