Client Application

TO BECOME A CLIENT: Complete this form, print it, sign and date it, and send it to the mailing address below with the initial retainer. This should be done only after you have contacted Jacques by phone or email and he has agreed to accept you as a client.

Jacques Chambers, CLU
Benefits Consultant & Counselor
2658 Griffith Park Blvd. #290
Los Angeles, CA 90039-2520

jacques@helpwithbenefits.com
Voice 323-665-2595

http://helpwithbenefits.com
FAX 323-661-6537

CLIENT INTAKE FORM

Name
Address
City State ZIP

Please contact me by (Check one or list several by number of preference.)

Preference
	Phone
	Fax
	Email
	"Snail" Mail at the above mailing address

DISCLAIMER

______ (Initial) I understand that Mr. Chambers cannot and does not make either warranties or guarantees regarding the outcome of the assistance he will provide for me. I am hiring him solely for the guidance and assistance, not for any promised outcome.

______ (Initial) I further understand that Mr. Chambers is not an attorney or licensed tax counsel. I also understand that any advice, recommendations, or information given by him is not to be construed as "legal advice" to my particular case or claim.

Having read and initialed the above statements, I request the assistance and advice of Jacques Chambers.

Dated at: _________________________________(City and State)

On this date: _________________________,200___

Signed: _________________________________________

Please give a general overview of the issue, problem or question that you wish help with: