Address:_______________________________________________

______________________________________________________

Telephone# used for this work: _____________________________

Experience & Spiritual/Psychic Abilities:

______________________________________________________

______________________________________________________

______________________________________________________

I understand that I am being retained to work at a psychic service.
It is my personal feeling or understanding that I possess psychic or
clairvoyant abilities.

I have read the foregoing and swear under penalty of perjury that it is
true to the best of my knowledge.

Dated: _________________________________________________

Number: _______________________________________________

Number Type: _________________ (type in one from the list below)
(Social Security #, Social Insurance #, Passport #, or Military #)