Certificate in Satir Systemic Brief
Therapy - CSSBT-14 (M)
(Commencement date 23-25 March
2017)
Application Form
Name:
(Mr/Miss/Mrs/Dr) _________________________________________ DOB/Age:______________________
Address(Residence):_______________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
Occupation/Designation:__________________________________________________
Tel:(O)______________________________ (Res.)____________________________
E-mail: ___________________________________ H/P: _______________________
Employer/Agency: ______________________________________________________
Employer’s
Address: __________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________
Academic
Qualification: 1.________________________Year graduated:___________
2.________________________Year
graduated:___________
Present job
responsibilities/description/nature of work:
_______________________________________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________________________________________
Brief description
of previous relevant experience pertaining to counselling:
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Reasons for
enrolling:
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Deadline for registration: 9 March 2017. To
register either a. e-mail your completed registration form & pay 1st
Installment course fee of Rm1,900.00 through online banking to Tan Leh Ou Maybank a/c No: 1142-3612-9050 & alert
recipient after payment @ warrentan2@gmail.com
Choice Makers Consultancy
#12-742
Mobile (or Whatsapp): +65-9631-3814
Tel: +65-6388
6538
Email: warrentan2@gmail.com
Website: choicemakersconsultancy.blogspot.com
Signature /
Date
