Order Form WV DOC Shoe Program Effective August 2018 Please Complete All Info on Reverse (Print Clearly)

Order Form WV DOC Shoe Program Effective August 2018 Please complete all info on reverse (print clearly).

TOTAL TOTAL ITEM DESCRIPTION PRICE ITEM # Size QTY PRICE ITEM DESCRIPTION PRICE ITEM # Size QTY PRICE SHOES Tennis Shoes Basketball Shoes Rawlings Marc II Velcro Tennis Shoe 6, 6.5, 7, 7.5, 8, 8.5, 9, 9.5, $28.00 / EA 81670-01 Adidas Ilation Mid Basketball Shoe 6.5, 7.5, 8, 8.5, 9, 9.5, 10, $60.00 / EA 80950-01 10, 10.5, 11, 11.5, 12, 13, 14, 15 ______15 ______Reebok Ridgerider Leather 2.0 Tennis Shoe - White 7, 7.5, 8, $57.00 / EA 81996-01 Fila Key West Court Shoes (Black/White) 7.5, 8, 8.5, 9, 9.5, 10, $40.00 / EA 81693-01 8.5, 9, 9.5, 10, 10.5, 11, 11.5, 12, 12.5, 13, 14, 15 ______10.5, 11, 11.5, 12, 13 ______Women’s Cross Training Shoes Nike Borough Low Court Shoe (White) 6, 6.5, 7, 7.5, 8, 8.5, 9, $75.00 / EA 81889-01 Rawlings Women’s Cross Training VIP Shoe (White) 5, 5.5, 6, $28.00 / EA 81669-01 9.5, 10, 10.5, 11, 11.5, 12, 12.5, 13, 14, 15 ______6.5, 7, 7.5, 8, 8.5, 9, 9.5, 10, 10.5, 11, 11.5, 12 ______

Nike Borough Mid Court Shoe (White) 6, 6.5, 7, 7.5, 8, 8.5, 9, $80.00 / EA 81888-01 Cross Training Shoes 9.5, 10, 10.5, 11, 11.5, 12, 12.5, 13, 14 ______Rawlings Espy Cross Training Shoe 6, 6 (2E), 6 (4E), 6.5, 6.5 $28.00 / EA 81668-01 (2E), 6.5 (4E), 7, 7 (2E), 7 (4E), 7.5, 7.5 (2E), 7.5 (4E), 8, 8 (2E), Nike Court Royale Court Shoes (White) 7.5, 8, 8.5, 9, 9.5, 10, $65.00 / EA 81726-01 8 (4E), 8.5, 8.5 (2E), 8.5 (4E), 9, 9 (2E), 9 (4E), 9.5, 9.5 (2E), 9.5 10.5, 11, 12, 12.5, 13, 14, 15 ______(4E), 10, 10 (2E), 10 (4E), 10.5, 10.5 (2E), 10.5 (4E), 11, 11 (2E), 11 (4E), 11.5, 11.5 (2E), 11.5 (4E), 12, 12 (2E), 12 (4E), 13, 13 ______(2E), 13 (4E), 14, 14 (2E), 14 (4E), 15, 15 (2E), 15 (4E), 16, 16 Phat Farm Prism High Top Basketball Shoes 7, 7.5, 8, 8.5, 9, $27.00 / EA 80150-01 (2E), 16 (4E), 17, 17 (2E), 17 (4E), 18, 18 (2E), 18 (4E), 19, 19 10, 10.5, 11, 12, 13 ______(2E), 19 (4E) Rawlings Kingdom High Basketball Shoes (White) 6, 6 (2E), 6 $32.00 / EA 81666-01 (4E), 6.5, 6.5 (2E), 6.5 (4E), 7, 7 (2E), 7 (4E), 7.5, 7.5 (2E), 7.5 Reebok Quickchase SE Cross Training Shoe 6.5, 6.5 (2E), 6.5 $55.00 / EA 81710-01 (4E), 8, 8 (2E), 8 (4E), 8.5, 8.5 (2E), 8.5 (4E), 9, 9 (2E), 9 (4E), (4E), 7, 7 (2E), 7 (4E), 7.5, 7.5 (2E), 7.5 (4E), 8, 8 (2E), 8 (4E), 9.5, 9.5 (2E), 9.5 (4E), 10, 10 (2E), 10 (4E), 10.5, 10.5 (2E), 10.5 8.5, 8.5 (2E), 8.5 (4E), 9, 9 (2E), 9 (4E), 9.5, 9.5 (2E), 9.5 (4E), (4E), 11, 11 (2E), 11 (4E), 11.5, 11.5 (2E), 11.5 (4E), 12, 12 (2E), ______10, 10 (2E), 10 (4E), 10.5, 10.5 (2E), 10.5 (4E), 11, 11 (2E), 11 ______12 (4E), 13, 13 (2E), 13 (4E), 14, 14 (2E), 14 (4E), 15, 15 (2E), (4E), 11.5, 11.5 (2E), 11.5 (4E), 12, 12 (2E), 12 (4E), 12.5, 12.5 15 (4E), 16, 16 (2E), 16 (4E), 17, 17 (2E), 17 (4E), 18, 18 (2E), (2E), 12.5 (4E), 13, 13 (2E), 13 (4E), 14, 14 (2E), 14 (4E), 15, 15 18 (4E), 19, 19 (2E), 19 (4E) (2E), 15 (4E) Skechers Serpentine Cross Training Shoe 6.5, 7, 7.5, 8, 8 Wide, $60.00 / EA 80945-01 Rawlings Urban Low Basketball Shoe (White) 6, 6.5, 7, 7.5, 8, $32.00 / EA 81667-01 8.5, 8.5 Wide, 9, 9 Wide, 9.5, 9.5 Wide, 10, 10 Wide, 10.5, 10.5 8.5, 9, 9.5, 10, 10 (2E), 10.5, 10.5 (2E), 11, 11.5, 11.5 (2E), 12, ______Wide, 11, 11 Wide, 11.5, 11.5 Wide, 12, 12 Wide, 13, 13 Wide, ______12 (2E), 13, 13 (2E), 14, 15 14, 14 Wide, 15 Wide, 16 Wide

Reebok Royal BB4500 Hi Basketball Shoes (White) 6.5, 7, 7.5, $65.00 / EA 80389-01 Skechers White After Burn Energy II Cross Training Shoes 7, $60.00 / EA 52910-01 8, 8.5, 9, 9.5, 10, 10.5, 11, 11.5, 12, 13, 14, 15 ______7.5, 8, 8.5, 9, 9.5, 10, 10.5, 11, 12, 13 ______

Women’s Running Shoes Casual Shoes Reebok Classic Royal Nylon Women’s Running Shoe (White) 5, $55.00 / EA 81677-01 Canvas Slip On (White) 5, 5.5, 6, 6.5, 7, 7.5, 8, 8.5, 9, 9.5, 10, $7.00 / EA 52938-01 5.5, 6, 6.5, 7, 7.5, 8, 8.5, 9, 9.5, 10, 10.5, 11, 11.5, 12 ______10.5, 11, 11.5, 12, 13, 14, 15 ______Reebok Harman Women’s Running Shoe (White) 5, 5.5, 6, 6.5, $65.00 / EA 82154-01 7, 7.5, 8, 8.5, 9, 9.5, 10, 11 ______DVS Barton Skate Shoe 7.5, 8, 8.5, 9, 10, 11, 11.5, 13, 14 $58.00 / EA 80955-01 ______Shoe Corp Leather Velcro Shoes 3, 4, 5, 6, 6 4E, 6.5, 7, 7 4E, $25.00 / EA 52097-01 Reebok Women’s Princess Low Running Shoes 5, 5.5, 6, 6.5, 7, $47.50 / EA 52635-01 7.5, 8, 8.5, 8.5 4E, 9, 9 4E, 9.5, 10, 10 4E, 10.5, 11, 11 4E, 12, 7.5, 8, 8.5, 9, 9.5, 10, 11, 12 ______12 4E, 13, 13 4E, 14, 14 4E, 15, 16, 16 4E, 17, 18 ______Running Shoes Adidas Energy Cloud Running Shoe - White 6.5, 7, 7.5, 8, 8.5, $67.00 / EA 81970-01 9, 9.5, 10, 10.5, 11, 11.5, 12, 12.5, 13, 14, 15 ______

Rawlings Chance III Running Shoe (White) 6 $28.00 / EA 81671-01 ______Reebok Classic Leather DTM Running Shoe 6.5, 7, 7.5, 8, 8.5, $65.00 / EA 81676-01 9, 9.5, 10, 10.5, 11, 11.5, 12, 13, 14, 15 ______

Reebok Classic Leather Running Shoes 7, 7.5, 8, 8.5, 9, 9.5, $65.00 / EA 50404-01 10, 10.5, 11, 11.5, 12, 13, 14, 15 ______

Reebok Royal Nylon Running Shoes - White 6.5, 7, 7.5, 8, 8.5, $55.00 / EA 81674-01 9, 9.5, 10, 10.5, 11, 11.5, 12, 13, 14, 15 ______

Reebok Run Supreme 2.0 LD Running Shoes 6.5, 6.5 (2E), 6.5 $48.00 / EA 81712-01 (4E), 7, 7 (2E), 7 (4E), 7.5, 7.5 (2E), 7.5 (4E), 8, 8 (2E), 8 (4E), 8.5, 8.5 (2E), 8.5 (4E), 9, 9 (2E), 9 (4E), 9.5, 9.5 (2E), 9.5 (4E), 10, 10 (2E), 10 (4E), 10.5, 10.5 (2E), 10.5 (4E), 11, 11 (2E), 11 (4E), 11.5, 11.5 (2E), 11.5 (4E), 12, 12 (2E), 12 (4E), 12.5, 12.5 ______(2E), 12.5 (4E), 13, 13 (2E), 13 (4E), 14, 14 (2E), 14 (4E), 15, 15 (2E), 15 (4E)

Total Total

K - Kosher • H - Halal • C - Clear • D - Diabetic • R - Resealable • G - Gluten Free • S - Soy Free Order Form WV DOC Shoe Program Effective August 2018 Please complete all info on reverse (print clearly). PROGRAM DATES: CATALOG CHANGES: Every effort has been made to show and We cannot send orders from one inmate to another. SHIP TO: Ordering Begins: August 1, 2018 describe the merchandise as accurately as possible. Because many manufacturers change an item’s design, color, package size and Inmate’s Name ID# WAYS TO ORDER: style after our catalog is produced, we reserve the right to discontin- Online: westvirginiapackages.com ue or change product specifications without prior notice. We regret Institution/Dorm/Housing# Phone: 1-800-546-6283 any changes that might occur and will make every effort to minimize Mail: Access Securepak (WV), 10880 Linpage Place St. Louis, MO these occurrences. Inadvertent errors in product descriptions, pric- 63132 ing and special offers are not binding on Access Securepak, and we may make adjustments at any time. Additionally, many of our food Street Address ACCEPTABLE FORMS OF PAYMENT: items may contain common allergens such as milk, eggs, wheat • Credit/Debit Cards—VISA, MasterCard, Discover and peanuts. Before consuming a food item, please consult the City State Zip • Prepaid cards that have a verifiable United States address product packaging for specific information on its ingredients. Prices SENDER: REQUIRED for order fulfillment. • Cashier’s check and offers are subject to change and available while supplies last. • Money order Always consult the westvirginiapackages.com website for the latest • Institutional Checks updates on this package program. Sender’s Name We do not accept personal checks and will return them to the sender. Credit/debit and prepaid cards will be charged on the day the In the event of a back order, may we substitute like items of equal or Street Address order is placed. Refunds or credits will be applied to the card used greater value? Note: unless you choose “NO,” we may substitute for

City State Zip for the order (allow additional time for refunds/credits on prepaid out-of-stock or restricted items. cards). Access Securepak reserves the right to remove one or more _YES _NO Phone Number items from the order due to insufficient payment. CUSTOMER SERVICE: Email (You will receive confirmation emails when the order is placed and shipped) SALES TAX: Access Securepak® is required by the state of West westvirginiapackages.com Virginia to collect sales tax on all merchandise and processing fees. Automated system is available 24 hours a day, seven days a week CALCULATE AMOUNT DUE: 1-800-546-6283 Merchandise Tax Totals Tax calculation example: Live bilingual representatives are available Monday through Friday, Taxable Items: x = $63.52 merchandise total + $5.95 processing fee = $69.47 subtotal 8:30 a.m.–11:59 p.m. EST, and Saturday, 11 a.m.–5 p.m. EST. Processing Fee: $5.95 x = $69.47 subtotal x 1.06 tax rate = $73.64 total due *see tax chart for your facilities rate ELIGIBILITY: Access Securepak verifies inmate eligibility before TOTAL AMOUNT DUE: shipping packages, if applicable.

SELECT PAYMENT METHOD: Facility Name Zip Code Tax Rate Facility Name Zip Code Tax Rate ¨ Institutional Check ¨ Cashier’s Check ¨ Money Order Anthony Correctional Center 24986 6.00% Mt. Olive Correctional Complex 25185 6.00% Make check or money order payable to ACCESS SECUREPAK

¨ VISA ¨ MasterCard ¨ Discover Beckley Correctional Center 25801 7.00% Northern Correctional Center 26041 7.00% Charleston Correctional Center 25301 7.00% Ohio County Correctional 26003 7.00% Cardholder Name Denmar Correctional Center 24946 6.00% Parkersburg Correctional 26104 6.00% Cardholder Signature Center / / Huntington Work Release Center 25701 7.00% Pruntytown Correctional Center 26354 7.00% Daytime Phone Number Today’s Date mm/dd/yyyy

Huttonsville Correctional Center 26273 6.00% Salem Correctional Center 26426 6.00% Credit Card Number Huttonsville Work Camp 26273 6.00% St Marys Correctional Center 26170 6.00% / Security code is last three digits of account Expiration Date Security Code number panel. Lakin Correctional Center 25287 6.00% Stevens Correctional Center 24801 6.00%