Dilts Strategy Group


DSG AUTHORIZATION INFORMATION FORM

Please Fill Out as Completely as Possible:


Your Name:
Your Name as It Should Appear in Your Listing:
Your Institute or Organization:

Your Mailing Address:
Street:
Apt. or Suite:
City:
State/Province:
Postal Code:
Country:

Your Professional Contact Email Address:
Your Professional Contact Telephone Number:
Your Professional Website:

Your Profession:
Previous Professions Relevant to Your Application:
Educational Degree(s):

For Which Programs Are You Interested in Being Authorized?

SFM I: Next Generation Entrepreneur

2-Year Authorization - $750 3-Year Authorization - $1000

1. Institute Where You Were Certified:
2. Institute Owner:
3. Trainer Name(s):
4. Days of Training:

SFM II: Collective Intelligence

2-Year Authorization - $750 3-Year Authorization - $1000

1. Institute Where You Were Certified:
2. Institute Owner:
3. Trainer Name(s):
4. Days of Training:

SFM III: Conscious Leadership and Resilience

2-Year Authorization - $750 3-Year Authorization - $1000

1. Institute Where You Were Certified:
2. Institute Owner:
3. Trainer Name(s):
4. Days of Training:

TOTAL AMOUNT DUE: $

Methods of Payment

Bank Transfer: Dilts Strategy Group will send a link to an on-line invoice to the Email Address you provided. You may then pay the invoice by direct bank transfer. If you are transferring from a European bank, we prefer that you use TransferWise, an international money transfer service which uses the actual currency exchange rate and charges minimal service fees. Otherwise we will provide instructions for completing the transfer.
or

Credit Card: Dilts Strategy Group will forward a link to an on-line invoice using the Email Address you provided. You may then pay the invoice by credit card.

or

Paypal: PayPal Dilts Strategy Group will Send a PayPal Invoice to the Email Address you provided.
or

Bank Check in US Dollars: If you do not have a US Checking account, you can request a check in US Dollars from your bank. Please make the check payable to Dilts Strategy Group and then send it to:

Dilts Strategy Group, 40520 Corte de Rubi, Murrieta, California 92562, USA

Applicant Information

Language Skills:
1. What is your native language?:
2. What other languages do you speak?:
3. How fluent are you in English?
(a) On a scale of 1-10 with 10 being highly fluent, what number corresponds to your verbal skills?
(b) On a scale of 1-10 with 10 being highly fluent, what number corresponds to your written skills?

Will you be translating the materials into another language? Yes No
If yes, which language?:

How do you plan to use the DSG/SFM materials?


I confirm that the above information is correct to the best of my knowledge.

Date:

Click here to when done.

Thank you! We will respond to your application as soon as possible.
If you have any questions, write to us at:
DiltsStrategyGroup@gmail.com