I, A. B., being made a prisoner of war, by the army of the thirteen United States in North America, do promise and engage, on my word and honor and on the faith of a gentlemen, to depart from thence to . . . . . . . . . . . . . . . . in the State of . . . . . . . . . . . . . . . . being the place of my destination and residence and there or within six miles thereof, to remain during the present war between Great Britain and the said United States, or untill the Congress of the said United States or the Assembly, or Convention, or Committee or Council of safety of the said state shall order otherwise, and that I will not directly or indirectly, give any intelligence whatever to the enemys of the United States or do, or say anything in opposition to, or in prejudice of the measures and proceedings of any Congress for the said States during the present troubles, or until I am duly exchanged or discharged. Given under my hand this day of A. D., 178–.