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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