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Please complete the application below in its entirety.


Full Name:

First Name


Last Name

Email:

ex: myname@example.com
Phone Number:

ex: (555) 555-5555
Address 1:


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(Apt., Suite, Box, Unit, etc.)

City:
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Zip Code:

choose:
Date of Birth:
Day

Year

SSN or Tax ID:


ex. 123-45-6789

Are you COMMITTED to the cause to STOP VIOLENCE against women and children?

Have you ever been convicted of a felony or misdemeanor?


A conviction does not automatically disqualify you, we evaluate each unique situation separately. Be VERY honest and detailed in your description.

If, yes: (Explain)

Have you ever been charged with a crime against women or children?

Do you unlawfully use a controlled substance?

Have you ever been involuntarily admitted to a mental institution?

Why do you want to be Certified as a Self-Defense Instructor?

Which Certification option do you prefer?

Please complete the following billing information to start your certification process. We will keep the information on file to cover your certification fee(s). The information will be held in the strictness of confidence and security.

Please Enter Billing Information:

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(Apt., Suite, Box, Unit, etc.)

City:

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Card Number:


ex: 1111-2222-3333-4444]

Exp: Month

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By typing your name below, you authorize Divas In Defense Inc. to charge you for Divas In Defense Certified Instructor training. In addition, you comply with the terms set forth in our Terms & Conditions. If you choose to be a Divas In Defense Certified Instructor, you will receive an electronic Certified Instructor Agreement to sign and return. You are obligated to submit a background check no less than 30 days old to Divas In Defense.

Please read our terms here.

Electronic Signature:

Please do not “CLICK” Submit Form more than once. Feel free to email trainer@divasindefense.com to confirm receipt of web form.

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