Dilts Strategy Group


DSG AFFILIATION 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 Affiliated? (You Must Already Be an Authorized User for The Program.)

SFM I: Next Generation Entrepreneur

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

SFM II: Collective Intelligence

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

SFM III: Conscious Leadership and Resilience

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


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?

Any other information relevant to your request to put on a DSG Affiliated program?


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

Date:

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