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BP-A0778 JUN 10 CREDENTIALS OF RELIGIOUS SERVICES CONTRACTOR U.S. DEPARTMENT OF JUSTICE FEDERAL BUREAU OF PRISONS PERSONAL PROFILE Name Address Telephone Religious Affiliation Civic Affiliations Professional Affiliations Country of Origin Citizenship Immigration Number If Landed Immigrant Naturalization Number If Naturalized Citizen Foreign Travel Countries Visited Last Five Years And Time Frames Funding from Foreign Governments Have you lived in the United States three of the last five years Yes No VERIFIABLE RELIGIOUS CREDENTIALING AUTHORITY Religious Certifying Authority such as Superintendent President Religious Superior Pastor etc. Title Local Congregation Name and Address Length of relationship with religious credentialing authority EDUCATION College Degree/Date Seminary/Graduate School Other Graduate Degree s As a religious service contractor I am aware of and agree to comply with Code of Federal Regulations Rule 548. 15 which states no one may disparage the religious beliefs of an inmate nor coerce or harass an inmate to change religious affiliation* Attendance at all religious activities is voluntary and unless otherwise specifically determined by the warden open to all* I do not endorse nor will I practice or use language in the institution that will support violence terrorism discriminate against other inmates or exclude other inmates from religious services based on race color religion gender or national origin* Signature of Contractor PDF Date Prescribed by P5360 This form replaces BP-S778. 053 dtd OCT 04 The Following Section to be Completed by the Religious Services Program Manager Ordination/Equivalent Yes Faith Group No Comments Interview Summary Comments If Needed Interview Date Program Manager s Signature Religious Subject Matter Expert SME Review If Needed Religious SME Recommends Contractor Date Reviewed Signature of Religious SME Chaplain Review I have reviewed the personal information presented by the prospective religious vendor. I recommend this vendor for consideration of award of contract. I do not recommend this vendor for consideration of award of contract. Chaplain Signature Attach Supporting Documentation e*g* copy of Immigration or Naturalization Number cc Contracting Office Contractor Security File. 15 which states no one may disparage the religious beliefs of an inmate nor coerce or harass an inmate to change religious affiliation* Attendance at all religious activities is voluntary and unless otherwise specifically determined by the warden open to all* I do not endorse nor will I practice or use language in the institution that will support violence terrorism discriminate against other inmates or exclude other inmates from religious services based on race color religion gender or national origin* Signature of Contractor PDF Date Prescribed by P5360 This form replaces BP-S778. 053 dtd OCT 04 The Following Section to be Completed by the Religious Services Program Manager Ordination/Equivalent Yes Faith Group No Comments Interview Summary Comments If Needed Interview Date Program Manager s Signature Religious Subject Matter Expert SME Review If Needed Religious SME Recommends Contractor Date Reviewed Signature of Religious SME Chaplain Review I have reviewed the personal information presented by the prospective religious vendor.

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