Microsoft word - premiere privacy client application.doc

________________________________________________ ________________________________________________ __________________________ State ________ Zip ________ Telephone number _________ Do you work for any government? _____ _________ Social security # ___________ Filing status ____ __ Real estate? _____ _____________________________________________________ _____________________________________________________ What is your primary concern regarding your current privacy, asset protection and financial situations? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ What is/are your primary objective(s) with Premiere Privacy Consultants? __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Do you currently have any liens, levies, attachments or judgments against you? Are any of your assets currently under bankruptcy protection? Are there any IRS Notices of Lien or Levy currently recorded against you? Are any of your assets listed in any wills or other testate documents? Are you the sole legal owner of the property you wish to protect? If not, please list on a separate sheet the names and addresses of any parties who hold joint or partial ownership with you, and the In order for us to properly develop a strategy to preserve your privacy, liberty, and property rights, we require information about your assets. All information submitted with this application will be kept strictly confidential. Under no circumstances will this information be shared with anyone outside of this organization. Please list any real property (land and structures) that you own. Indicate with a "p" if you are only a partial owner. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Please list any vehicles that you own, including year, make, and model. Do not include leased vehicles. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Please list any foreign or domestic bank accounts, stock holdings, annuities, pension or retirement accounts, or other liquid assets or liquid asset holdings you own. Indicate with a "p" if you are only a partial owner. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ I hereby authorize Premiere Privacy Consultants to assist and support me in designing a strategic program to protect my assets, liberty and natural rights as a freeborn individual. I understand that Brent-Emory.Johnson is not an attorney, nor is he a member of any BAR Association, nor has he represented himself at any time as an attorney. I understand that it is my sole responsibility to determine the validity of and authorize any course of action that Brent-Emory.Johnson and Premiere Privacy Consultants might recommend. Further, I understand that it is my sole responsibility to verify the validity of the information and recommendations provided by Premiere Privacy Consultants and that in any action I might choose to take as a result of what I learn from any consultation with a Premiere Privacy Consultants representative, I will hold harmless Brent-Emory.Johnson, Premiere Privacy Consultants, Truth and Freedom Foundation, and any of their agents or representatives from any responsibility or liability whatsoever as a result of their recommendations and authorized actions conducted on my behalf. I hereby and forthwith declare that I am not currently nor have I ever been an agent for the United States government, or any related corporate body-politic government entity or instrumentality, including without limitation, the Federal Reserve Bank, U.S. Postal Service. Dept. of Immigration and Naturalization, Internal Revenue Service, Dept. of the Treasury, Federal Bureau of Investigation, Bureau of Alcohol, Tobacco and Firearms. I am not a resident of the District of Columbia. I am not a law enforcement officer. ___________________ Premiere Privacy Consultants is a division of Truth and Freedom Foundation

Source: http://www.freedomradio.us/vof/images/forms/prem_privacy/ppc_client_application.pdf