The Magnus Institute

17 Kings Street,
Chelsea,
London, SW3 3QR
+44 (0)20 7594 4740
sharonemalka

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Statement of:_____________________________ Date:__________________

Regarding:__________________________________________________________
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On the following pages, please describe to the best of your recollection the unusual, esoteric, or paranormal
event you have experienced. Use as much detail as possible, and use full names of any persons mentions.

By signing this document of _____ pages, I hereby declare that the facts and events presented therein are
correct to the best of my knowledge.

Signature:_________________________ Date:________________

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Page ____ of _____ Signature: ________________________
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 The Magnus Institute
17 Kings Street,
Chelsea,
London, SW3 3QR
+44 (0)20 7594 4740
sharonemalka

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Page ____ of _____ Signature: ________________________
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