DSA Bus-Membership App

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DSA Group Membership Application Questionnaire

Group Representative Name*

Phone number:*

Email Address*

Notification Preference*

Name of Business / Organization*

Group Category*

Number of years in Practice (for clients)*

Challenges or Problems you were able to overcome through your practice

Headache/MigraineInsomniaBack pain (Upper)Back pain (Lower)Shoulder/Neck painAllergyChronic FatigueStressDepressionDigestion problemDiarrhea, ConstipationBreathing problemNervousness/AnxietyHigh blood pressureLow blood pressureMemory lossSinusNeed for Creative expression & having funOther

Other Challenges or Problems you have overcome

Challenges or Problems of your clients you've helped to overcome*

Other Challenges or Problems of your clients you've helped overcome

Gift Ticket Specification: Name (< 30 characters) and $ value*

Gift Ticket Specification: Description in terms of quantity and quality of product or service deals/package you offer - It should include lead time for the delivery of product or service, gift ticket validity period, and redemption location*

I declare under penalty of perjury that the foregoing is true and correct.*

Agree

Executed on (date)*

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Thank you for completing your DSA Membership Application Form. We look forward to supporting you in exchanging your gifts and meeting your needs & desires! Namaste, Divine Spark Allies