Application Form

Name on I.D. *

Name to appear on certificate *

Mailing Address *

Mobile Number *

Secondary Contact *

Email *

Date of Birth (DD/MM/YYYY) *

What's one area of your life you most hope to improve in? *

How did you get to know us? (If someone introduced our course to you, please let us know his/her name so that we can thank them.) *

What made you decide to take this programme? *

Comments or anything you would like us to know?

Are you suffering from any learning disability? *

Are you under any medication related to a psychological disorder? *

Are you clinically diagnosed with a psychological disorder? *

If "YES", for the three questions above, please indicate available information, if "NO" just fill in "NIL" ? *

Our Programme *

Dates of Commencement *

Indicate Dates above by (DD/MM/YYYY) or TBA if not listed.

Terms and Conditions: *

I agreed

• Deposit $1,000 can be paid during this application and full payment before course commencement date. • The investment amount covers entry to the event only. Travel, food & accommodation (if any) are not included. • For PAYNOW / STRIPE Credit card payment, an email invoice will be sent to the above designated email address • I acknowledge that I have not been diagnosed by a medical professional for any known psychological condition. • I understand this programme is meant as a means for personal self-help and if need be, I will seek professional or psychological assistance when needed. • I understand for the programme to be effective I would need to be engaged and practice the homework designated by the trainer.

Acknowledgement *

I agreed

I hereby acknowledge, having read understood and agreed to abide by the terms & conditions set out by “DASETi” and “DASETi Academy”. I note that my purchase is only for the training held on the date and location stated in this order form and the sale will be considered as fulfilled even if I fail to attend it.

Electronic Signature *

[Electronic Signature Agreement] By keying in my name, I am signing this agreement electronically. I agree my electronic signature is the legal equivalent of my manual signature on this agreement and I hereby declare that the information given in this application is true and correct to the best of my knowledge and belief. With this Electronic signature I consent to be legally bound by the terms and conditions listed below.