Bureau of Recordation · Office of the Chief

Confederation Intake

Please fill out the form below in its entirety and submit it to our Confederation Formation Specialist. Do not worry if there are negative items in your background — so long as you honestly complete the form and provide context as necessary, your application will be reviewed. It is a privilege to hold a Confederation; approximately 66% of applicants are approved on merit and worth.

Important. Completing this form does not create a Confederation, citizenship, Active license status, or attorney–client relationship. False or incomplete answers may result in denial and may be referred for integrity review. Sensitive identity numbers may be completed offline with Recordation if you prefer not to transmit them here.

A. Identity (CIS)

Legal first name

Middle name(s)

Legal last name

Suffix

Other names used (aliases, maiden, former legal names)

Date of birth

Place of birth (city, state/province, country)

Sex

Citizenship / nationality

Primary government ID type

ID number

ID issuing jurisdiction

Tax ID last 4 (SSN / ITIN / national tax ID)

Full tax ID is collected under seal during background screening if intake advances.

Upload government ID (passport, driver license, or national ID)

Required. Clear color scan or photo of the photo page / front of ID. PDF or JPG/PNG/WebP. Max 10 MB.

Second page / back of ID (optional — recommended for driver licenses)

Optional. Use for the reverse of a driver license or a second passport page if needed. Max 10 MB.

B. Contact & address

Primary phone

Alternate phone

Physical / residential address

Mailing address (if different)

Years at current address

Prior address (if less than 3 years at current)

Emergency contact — name

Emergency contact — phone

Emergency contact — relationship

C. Occupation & employment

Current occupation / profession

Employer / firm (if any)

Employer jurisdiction (state / country)

Years in this field

Employment status

Brief employment / career history (last 5–10 years)

D. Other businesses owned (include jurisdiction)

List every entity you own or control (or owned/controlled in the last 10 years), including jurisdiction of formation and registration number if any.

Businesses — name, role/ownership %, jurisdiction, entity type, status

Do you currently own or control any business?

Professional / regulatory licenses held (and jurisdiction)

E. Proposed confederation

Why do you want a Confederation with the KiKiallus Nation?

Brief overview of what the Confederation will do

Projects (current or planned)

Do you have active projects today?

Will the Confederation sell goods or services?

Describe goods, services, or other activities in more detail

Proposed Confederation name (if known)

Primary capital / funding source (summary)

Jurisdictions where the Confederation will operate

F. Arrests, charges & litigation

Have you ever been arrested?

Have you ever been convicted of a crime?

If yes to arrest or conviction — dates, charges, jurisdictions, dispositions

Have you been a party to past litigation (civil, criminal, administrative, bankruptcy, regulatory)?

Any pending litigation, investigation, or enforcement action?

Litigation / investigation detail (case names, courts, jurisdictions, status, role)

Bankruptcy filing (personal or controlled entity) in last 10 years?

Subject to sanctions, debarment, or watchlist (self or entity)?

G. Military & law enforcement

Are you a military veteran?

Branch / service (if veteran)

Are you, or have you been, law enforcement?

Agency / role / years (if LE)

H. How you found us & referrals

How did you find the KiKiallus Nation?

Please explain (search terms, event name, etc.)

Referrals (list names and contact info of anyone who referred you)

I. Attestations & consent

I certify that the information in this CIS / intake is true, complete, and not misleading to the best of my knowledge.

I consent to agency-level background screening and to verification of identity, businesses, litigation, and references as part of Confederation review.

I understand that submission does not create a Confederation, Active license, citizenship, or any right to use the Nation’s name or seals.

I agree to promptly update Recordation if any answer changes materially during review.

Electronic signature (type full legal name)

Date

On submit, this intake (including your government ID upload) is delivered automatically to the Confederation Formation Specialist and routing offices. No email client is opened.