[Three hyphens (---) indicate the beginning of a new section of the form; five hyphens (-----) indicate the beginning of a new page.]

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Union™ Supply Direct
California Quarterly Package Order Form

Nuestro sitio web ya está disponible en español
Simplemente haga clic en el botón en la esquina superior derecha.

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Shipping To (Envío Para):

Inmate Name (Nombre del recluso): William Goehler
Institution Name (Institucion): Mule Creek State Prison
Institution Address (Direccion):
City (Ciudad): Ione
State (Estado): CA

⌧ PG: A/B
☐ PG: D
⌧ MALE
☐ FEMALE

Inmate # (Número de Preso): K77832
Dorm / Housing (Dormitorio / Cuarto): B9-244
PO Box #: 409040
Zip (Códrigo Postal): 95640

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From (De):

☐ New Customer (Nuevo Cliente)
☐ Existing Customer (Cliente Existente)
☐ Existing Customer (Update My Info) (Cliente Existente, Actualizar Informacion)

Sender's Name (Nombre):
Email (we will send your invoice here):
Address (Direccion):
Phone # (Teléfono):
City (Ciudad):
State (Estado):
Zip (Código Postal):

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Select Payment Method (Seleccione un método de pago):

☐ CONTEST WINNER CERTIFICATE (Certificado de Ganador del Concurso)
Certificate Code (Código del Certificado):

ACE CASH EXPRESS® (SEE INSTRUCTIONS ON PAGE 417 AND ON OUR WEBSITE)
☐ Money Order* (Orden de Pago)
☐ Mastercard
☐ Visa
☐ Discover
☐ Facility Check (Cheque de Facilidad)
☐ Cashier's Check (Cheque de Caja)
☐ Personal Check* (Cheque Personal)
☐ NEW Prepaid Account (Nueva cuenta de prepago) (See page 416 of our Quarterly Catalog for details)

LAYAWAY PROGRAM (SEE INSTRUCTIONS ON PAGE 417. LAYAWAY PROGRAM IS FOR FRIENDS & FAMILY ONLY)
☐ Money Order* (Orden de Pago)
☐ Personal Check* (Cheque Personal)
☐ Credit Card

Please make all Checks or Money Orders payable to Union Supply Direct. *All personal checks must have Name, Address & Phone Number imprinted on the check. *We only accept domestic money orders issued in the U.S.

[table with 4 rows and 4 columns]
CARD TYPE: | CARD WILL BE CHARGED: | WHAT HAPPENS WHEN YOUR ORDER IS PLACED? | ADDITIONAL INFORMATION:
Credit* | When order ships | There will be a hold on your credit card for the amount of the order ta the time the order is placed. | The hold on your card will be removed and your card will be charged at the time the package ships.
Debit* | When order ships | There will be a hold on your debit card for the amount of the order at the time the order is placed. | A positive balance must be kept in the account until the package ships at which time your card will be charged.
Prepaid* | When order is taken | Funds are deducted from your card and placed on hold at the time the order is placed. | A positive balance must be kept in the account until the package ships at which time your card will be charged.

Credit Card Number (Numero de tarjeta): ▯▯▯▯▮▯▯▯▯▮▯▯▯▯▮▯▯▯▯
Expiration Date (Fecha de vencimiento): ▯▯▮▯▯
Last 3 Digit (CVV) Code (Código de seguridad): ▯▯▯

ON BACK OF YOUR CREDIT CARD
[arrow pointing to an example CVV number on image of credit card]

Cardholder's Name (Nombre del dueño de tarjeta):
Phone # (Teléfono):
Cardholder's Address (Must match sender's address.) US address only:
State (Estado):
Zip (Código Postal):
Cardholder's Signature (Firma del dueño de tarjeta):
Date (Fecha):

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FOR OFFICE USE ONLY
[an open box with 13 cells]

The California Department of Corrections and Rehabilitation (CDCR) has approved this independent vendor to sell merchandise to inmates and the public. CDCR's brief review and approval of this vendor was strictly limited to minimum security requirements and general business intent. CDCR is not affiliated with this vendor and does not guarantee that the vendor will fulfil any obligations, perform as expected, nor permanently remain in business, nor does CDCR guarantee the vendor's products in any way. Any purchases from this vendor are at the buyer's sole risk. CDCR assumes no liability whatsoever for such purchases, nor any aspect thereof. Any issues or disputes regarding the vendor's products are the sole responsibility of the buyer and/or the vendor, and CDCR is not obligated to mediate or resolve any such disputes.

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p.1

Please check the appropriate quarter (Only 1 package per quarter allowed)
Por favor verifique el trimestre apropiado (Solo 1 paquete por trimestre permitido)
☐ 1ST QUARTER (JANUARY 1 - MARCH 31, 2021)
☐ 2ND QUARTER (APRIL 1 - JUNE 30, 2021)
☐ ADDITIONAL QUARTERLY PACKAGE (REFER TO RULES & REGULATIONS ON PAGE 412)

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[table with 8 columns and many rows]
[the first three rows of the table:]
QTY (CANTIDAD) | ITEM # (NUMERO del ARTÍCULO) | DESCRIPTION/COLOR (DESCRIPCION/COLOR) | SIZE (TAMAÑO) | WEIGHT OZ. (PESO EN ONZAS) | EXTENDED WEIGHT (OUNCE X QTY) (PESO TOTAL (ONZAS X CANTIDAD)) | PRICE (PRECIO) | EXTENDED PRICE (PRICE X QTY) (PRECIO TOTAL (PRECIO X CANTIDAD))
1 | 5508009 | WESTBEND 8" FAN | | | 58 | | 25.00
1 | 1003211 | NEW BALANCE BB581 WT | 11 | | 42 | | 49.50

[written freehand in pen, over the table lines:]
PORK/BEEF/FISH/ETC.

And a vast selection in the BLOWOUT SALE section
CaliforniaInmatePackage.com

Anybody out there? I'm one of the few who didn't apply for the Covid stimulus check here in prison, since seemed like fraud to me. I am in real need of replacing old shoes and a burned out fan though. If anyone out there is interested in helping me with those, the following are merely good deals to add if possible.

Thank you
WG 1/22/21