To whom it may concern.

As a God fearing Christian, I am requesting religious exemption from anything foreign placed in or on my body not from or created by God. My faith and belief in God overrules any man made created substance or technology, that if allowed to be used on me, would alter my my being born in the perfect image of God. The Holy Spirit resides in me and is giving clear direction in knowing what I do with my body is my choice, and my choice alone and no one has the right to force me to put something into my body. Anything outside of that runs into tyranny and injustice from a satanic origin. The Lord Jesus will heal any infirmity, and I put my faith in His protection and healing powers if it arises I fall ill in any way.

Life is sacred and very precious to God. To murder a unborn child and chop them up for science experimentation is abhorrent. The very process of how a “vaccine” is created, in many cases, if not all, is from these same murdered children. I in no way, shape or form want anything to do or be connected to that sin. The ten commandments of God tells us “Thou shall not kill.” Participating in a “vaccine” that utilized human fetuses purposely killed in the womb would make me complicit to a murder charge and being sent to Hell. No thanks. The Bible clearly states that before God formed us in the womb, he knew us. God loves children and He says children are a heritage from the Lord, whatever the age. God also tells us in His Word that He hates the shedding of innocent blood and that He knits us together in our mothers womb. That means the second the seed enters the egg, life has started. A soul has been created at that very instant. I want no part in putting another persons soul in my body.

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Furthermore, Gods Word tells us that in the Last Days before He returns in all His glory, one sign would be that there would be pestilences that would come upon the earth and that because of a great delusion, many would take the mark of the beast. Satan has put us under bondage by a man-made bio weapon and also has rolled out this “vaccine”, another man made creation which in fact is not the cure, but the actual sickness. Man is evil and full of sin and my trust goes to only one place. God. Gods Word clearly states anyone taking that mark will spend eternity in Hell. I do not wish to go to Hell and pray you don’t either.

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It is a well know fact that the manufactures of these “vaccines” have no liability whatsoever if one gets sick, maimed, or dies after injection. That puts the burden on you who are mandating I take this. Are you willing to put yourself in that jeopardy? Many thousands who have taken this “vaccine” are having horrible results and studies are coming out by the day on it’s dangers. Those that comply with your unconstitutional mandate will probably put you out of business with lawsuits by damages caused. Also those who are fired for objecting to this unconstitutional mandate will, I’m quite sure, start legal action for damages caused by your actions. Why would you put yourself or employees faithful to you in that position?

To be a participant in nothing more than a giant experiment to have world control of the population and domination by a select few goes against all my beliefs and the preamble of the Declaration of Independence: We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. Unalienable rights supersede governmental laws and cultural norms. A few of these these natural rights include the right to think for oneself, the right to life, and the right to self-defense, and are unwavering till the day we die. God has given us all these rights. The original founders of the United States did also. I am invoking these three right now.

As far as needing a actual church building or “pastor” needing to cosign, that is not possible. The Bible clearly instructs that His believers are the temple of God and that the church is invisible. That leaves all liability and instruction to me and so this church certifies that I do not want to take this vaccine both on moral grounds and religious belief.

So it is in good conscience I hereby request exemption from taking this “vaccine” and being forced by anyone to go against my beliefs. That would be unethical, inhumane, and in violation of my Christian faith. Any coerced medical treatment of any kind goes against God and my religious faith and the right of one self to control their own medical treatment. And it also gives me the right to not to be ostracized or singled out in any way that would not allow me to be free to do as I want and/or putting me in restrictions. This mandate also is a violation of Nuremberg Code.


I faithfully execute this declaration this       day of            in the year of

Printed name                                                                    Signed


In the event my religious exemption and the Constitution of the United States is superseded by your mandate that I must take a forced mandatory vaccination to continue employment, a matter of clear responsibility now falls into your hands for my health and welfare thereafter after taking said vaccine due to your forcing me no other choice. As such you agree to the following:

_________________(company name and federal tax I.D) ______________(company owner) _______________(person in charge making request I take vaccine) _____________________________________(full address, phone number) take full responsibility for any negative effects vaccine may cause to my employee. If  mandated vaccine in any way, shape, or form causes harm and/or any type of  medical situation I as owner of company and my representatives agree to have full responsibility for full compensation of any injury’s resulting from vaccine for the lifetime of my employee. In the event of employee death within twenty (20) years, a payment of  twenty five million (25,000,000) will be given to employees family or next of kin within thirty (30) days of death of employee.  _______________(name of employee) Furthermore,  I(we) hereby agree, without reservation, that should my employee at any time suffer or develop any permanent condition deleterious or injurious to my employees health as a result of this decision of my company , I will personally pay for any and all costs involved relating to the care and treatment necessary for this patient for the rest of (his/her) natural life. I further agree that if my earnings are insufficient to meet these costs, I will sell my home, my business and all of my material possessions and put those proceeds towards meeting the patient-involved expenses if needed. Furthermore, as the fully authorized, designated owner of _____________(business owner) and _________________(representative) I agree to full responsibility stating that mandating this forced mandate of vaccinating my employee_____________(employee name) falls upon my shoulders, shareholders, and any and all those in leadership or ownership position thus allowing opportunity if my funds are unable to satisfy any injury, employee can pursue compensation from such and all. I agree to pay any and all employees  lawyers fees if  needed.


Further more, I request whoever is administering the vaccine to fill out this form if you are forcing me to take it. Due to safety concerns, please have Doctor and/or Health care worker that will providing and administering vaccine fill this out for my records. Objecting to fill this form out gives me full exemption from forced vaccination to stay employed and I will seek monetary damages to the fullest extent if you as my employer force me to still take if below warranty of my safety and health is not returned to me completed in full.


Physician or Health Care Professional’s Attestation and Warranty of Vaccine Efficacy and Safety

I (Physician or Health Care Professional’s name and,degree)

_________________________, _____ am a physician licensed to
practice medicine in the State/Province of ________________, in the country of
_________________. My State/Province license number is _______________ , and (if the USA)
my DEA number is _______________. My medical specialty is ________________________
I have a thorough understanding of the risks and benefits of all the medications that I prescribe for or administer to my patients. In the case of (Patient’s name) ___________________________ , age
_________ , whom I have examined, I find that certain risk factors exist that justify the recommended vaccinations. The following is a list of said risk factors and observations for the Covid19 Virus and the vaccinations that are used:
Vaccinations to choose from by manufacturer: _____________________________________________________
Risk Factor ____________________________________________
Current statistics of survival rate of unvaccinated _________________

Current statistics of those that have taken Covid 19 vaccinations and been harmed by taking it _______________________________________

Current statistics of those who have taken vaccine(s) and caught Covid19 anyway ________________________________________________________

I will be administering this vaccine:

manufacturer’s name ________________________, serial number ___________________,

batch number _____________________, expiry date____________________.
Signature of Physician or Health Care Professional ______________

I am aware that vaccines typically contain many of the following fillers and by no way is this a complete list. I have also given patient a EXACT list of ingredients from manufacturer of vaccine I am administering and explained in detail it is totally safe…..

aluminum hydroxide,                          human diploid cells,

hydrolized gelatin,                              (originating from aborted

aluminum phosphate,                           human fetal tissue),

ammonium sulfate,                             squalene (from shark livers),

amphotericin B,                                  latex,

animal tissues,                                    hydrolized gelatin,

pig blood,                                            mercury (thimerosal),

horse blood,                                        monosodium glutamate (MSG),

rabbit brain,                                        neomycin, neomycin sulfate,

dog kidney,                                         phenol red indicator,

monkey kidney,                                  phenoxyethanol (antifreeze),

chick embryo,                                    potassium diphosphate,

chicken egg,                                        potassium monophosphate,

duck egg,                                            polymyxin B, polysorbate 20,

calf (bovine) serum,                            polysorbate 80,

betapropiolactone,                              porcine (pig) pancreatic,

fetal bovine serum,                             hydrolysate of casein,

formaldehyde,                                     residual MRC5 proteins,

formalin, gelatin,                                sorbitol, sucrose,

glycerol,                                              tri(n)butylphosphate,

VERO cells,                                        sheep blood.

  (monkey kidney)                          aborted human baby parts

retroviruses and/or carcinogenic or other forms of infectious    mycoplasmic agents

…..and hereby warrant that these ingredients are safe for injection into the body of my patient including all ingredients in the vaccine I am administering for Covid19.
I hereby warrant that the vaccines I am recommending for the care of (Patient’s name) x______________and what I am injecting are experimental in nature and where usually vaccines take many years to even considered as usable, no one knows as to whether this vaccine is even safe and only time will tell as this technology has never been injected into humans till now. I understand what I am administering is (mRNA) technology and questionable that it should be called a vaccine due to how it’s made. I take full responsibility for any negative effects it may cause to my patient including not only my medical insurance, but also my personal belongings if said vaccination causes any harm to patient. I hereby agree, without reservation, that should this patient at any time suffer or develop any permanent condition deleterious or injurious to my patient’s health as a result of this treatment, I will personally pay for any and all costs involved relating to the care and treatment necessary for this patient for the rest of (his/her) natural life. I further agree that if my earnings are insufficient to meet these costs, I will sell my home, my business and all of my material possessions and put those proceeds towards meeting the patient-involved expenses. Furthermore, as the fully authorized, designated and currently employed representative of (Your Employer Name or Government Agency)________________, and acting in that capacity under personal penalty of perjury, who has been granted complete and unconditional authority to contractually bind (Your Employer Name or Government Agency)________________, under full acceptance of commercial liability, I do hereby bind as legally liable (Your Employer Name or Government Agency)_________________ for the lifelong medical and private care of the patient as well as all financial hardship incurred by the patient as a result of said deleterious or injurious effects of said vaccine(s), should they occur. There is no timeline and patient is warranted for the rest of their life that this vaccine is safe.

Signature of Physician or Health Care Professional’s name ______________

What I am administering:

This vaccine does not contain any tissue from aborted human
babies (also known as “fetuses”). In order to protect my patient’s well being, I have taken the following steps to guarantee that the vaccines I will use will contain no damaging contaminants.
STEPS TAKEN: __________________________________________________________
I have personally investigated the reports made to the VAERS (Vaccine Adverse Event Reporting System) the FDA, The CDC, and State I’m injecting this vaccine in, and that it is my professional opinion that the vaccines I am recommending are safe and all liability lies on me and my employer as such and any of those aforementioned for administration of this vaccine. I have on this _________day of ___________________(month), A.D._________(year),
administered this vaccination/medication/drug AFTER advising the above named patient that there is no risk involved with this vaccination, medication, drug therapy or treatment to the good health of my patient whatsoever.  Furthermore, and not withstanding my patient’s religious objections and medical concerns regarding the possible inclusion of scripturally unclean and possibly diseased animal remains as well as aborted human fetal tissues contained within the vaccine(s) in apparent direct violation of  (Your Employer’s Name or Government Agency)_________________ own ethical standards and corporate policy of No Harassment/Discrimination, as well as federal, state and international laws, treaties and conventions, or the extensive list of cautions and warnings of the very real possibility of severe adverse reactions as so listed on the vaccine manufacturer(s)’ own package insert(s), or the high number of adverse reports against said vaccine(s) that have already been recorded worldwide, or the apparent complete absence of any verifiable and independent, peer reviewed, long term, double blind and placebo controlled in vivo studies confirming the safety and/or efficacy of said vaccine(s), or my patient’s assertion that he/she has already been exposed to both this year’s seasonal and Swine flu strains and covid19 and it’s variants, and has overcome them both with no difficulty or residual adverse effects whatsoever thereby having already been conferred long lasting and heightened immunity against said strains, and in spite of my patient’s assertion of chemical sensitivity and/or allergies to numerous chemical and biological substrates, additives and adjuvants possibly contained within said vaccine(s) as well as the irrefutable fact that due to the proprietary nature of some ingredients, that those ingredients may not even be required to be listed on the package insert(s), thereby rendering as scientifically impossible a medically objective risk/benefit assessment on behalf of my patient, as well as my being totally unfamiliar with my patient’s past medical history or unique and untested physiology, I nonetheless attest and warrant that these ingredients are effective and safe for injection or inhalation into the body of my patient. Reports to the contrary, such as reports that mercury thimerosal, as example, causes severe neurological and immunological damage, are not credible. Ingredients I have reviewed in the vaccine I am administering are guaranteed by me to be 100% safe.
The bases for my opinion are itemized below.

In addition to the recommended vaccinations as protections against the above cited risk factors, I have recommended other non-vaccine measures to protect the health of my patient. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 I am issuing this Physician or Health Care Professional’s Attestation and Warranty of  Vaccine Efficacy and Safety in my professional capacity as the attending physician and/or health care professional to (Patient’s name) _________________________.
Regardless of the legal entity under which I normally practice medicine, I am issuing this statement in both my business and individual capacities and hereby waive any statutory, Common Law, Constitutional, UCC, international treaty, and any other legal immunities from liability lawsuits in the instant case.

I issue this document of my own free will after consultation with competent legal counsel whose name is________________________, an attorney admitted to the Bar in the State of ___________________, as well as________________________, Supervisor, Department Head, President, CEO, or Company Owner.




_________________________________,                       _______________________________,

Signature of Attorney.                  Signature of: Supervisor, Department Head, President,                                                            CEO or Company Owner


Printed Name of Responsible Physician or Designated Health Care Professional.



Signature of Responsible Physician or Designated Health Care Professional.



____________________________,                                                  ______________________________.

Printed Name of Witness                                   Signature of Witness




Subscribed and Sworn before Me on this_______day of ____________________, A.D.__________.


Notary Public: _________________________________________,


County: _________________, State:___________________.


My Commission Expires: ____________________________________.


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