Facility Information Form

Please provide the following information to request a Free4Life installation of The Word Network channel in addition to donated satellite equipment for your correctional facility completely of charge. We recommend you consult with your maintenance or engineering department to provide the technical portion of the form. Your warden or authorized representative must approve the application.

About Your Facility Name of your Facility: Security Level: Minimum Medium Maximum No. of Inmates: Men Women Juveniles Address: City: State: Zip: Engineer/Maintenance Contact Person: Title: Phone: ( ) Fax: ( ) Email:

About Your Facility’s Current Television Distribution System Question 1: Is your facility currently wired for video distribution? No If yes, please answer the questions below. If no, please skip to Question 2. How many television sets are connected? Number of Head End Rooms (where video distribution equipment is located)? If yes, are there multiple units/buildings that have separate TV distributions? Yes No What building is the Head End Room located in? (Please be specific on location, i.e. Bldg. C, Equipment Room)

Question 2: If your facility does NOT have video distribution, what area would you like connected to receive Free4Life? (Chapel, Day Room, etc. – Please be specific, i.e. Building A, Day Room)

Does the facility receive local cable channels? Yes No If yes, please give name of cable system (Please indicate if this is a correctional cable provider):

Does the facility have a broadcast antenna installed? UHF VHF None Does the facility receive satellite broadcasts? Yes No If yes, what satellite systems are installed? DirecTV TBN Glorystar C-band No DBS Other

I approve The Word Network channel to be installed at our facility. Name: Title of authorized representative:

Thank you and we look forward to serving you!

3 Ways to Submit this Form: 1. To submit this form electronically, click the SUBMIT button. A copy will be sent to your email address. 2. You can save the interactive form to your computer and hit SUBMIT at a later date. The form also can be attached SUBMIT manually to an email and sent to [email protected]. 3. Last option, you can FAX the completed form to Glorystar Satellite at (916) 644-6312