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STATEMENT OF APPLICANT I certify that I am authorized to act as the legal representative of who is a Jicensed member of the bar of the State of. I request that I be allowed to interview and correspond with , Federal Register Number , who is contined at the MDC/ MCC, Iam aware of my responsibility as a representative of the above-named attorney and certify that I am able to meet this responsibility. Iam also aware of the Bureau of Prisons’ Policy on Inmate Legal Activities and certify that [ am able to and will adhere to the requirements of this policy. I pledge to abide by Bureau of Prisons regulations and institution guidelines. I hereby certify that all of the information contained in this questionnaire is true and correct to the best of my knowledge. Furthermore, I understand that all informatton contained in this questionnaire may be investigated and verified through the use of federal, state and local authorities. Applicant’s printed name: Applicant's signature: Date Completed: Private Investigators must submit a copy of their Private Investigators Certificate and Private Tuvestigator’s photo identification. Page 7 of 10 Revised 2/01/08 DOJ-OGR-00023773