News Interview Authorization

• Legal Form Number: BP-A0233
• Date: 2010-06
• Year: 2010
• Section: Federal Bureau of Prisons

BP-A0233 NEWS INTERVIEW AUTHORIZATIONCDFRM

JUN 10

U.S. DEPARTMENT OF JUSTICEFEDERAL BUREAU OF PRISONS

Date

Inmate’s name and number (print)

Name of Institution

Name of news media representative

Address of media represented

I, the above-named inmate, do hereby freely give permission to the above-named

news media representative to interview me on or about date: and I do

hereby authorize the news media represented by this person to use any information

gathered about me during this interview for any legitimate purpose. I further

authorize the Bureau of Prisons and the Department of Justice, and their authorized

representatives, to release to representatives of the news media any documents or

information relating to allegations or comments made by me in this interview.

Inmate’s Signature

Witness Title

I, the above-named inmate, refuse permission to the above-named news media

representative to interview me.

Inmate’s Signature

Witness Title

****

I, the above-named inmate, do further freely give permission to the above-named

news media representative to make recordings of my voice during this interview and

to make photos of me (still, movie, or video) and I do hereby authorize the use of

such pictures or recordings by the news media represented by this person for any

legitimate purpose.

Inmate’s signature

Witness Title

Record Copy - Inmate’s File; Copy - Media Representative

PDF

Prescribed by P1480

This form replaces BP-233(14) dated JULY 1979.