Scholarship Application
This is for individuals to complete to apply for the QAS service at a reduced rate. It is our way of giving back for those that want change. Once the completed application
First Name *
Last Name *
My email address is : *
A brief description how I got to this service or what drew me here? *
Why are you requesting a Scholarship? *
What services do you wish to apply for and who? (ie; Empower service? Location? Situation? and is it just for you or others in your family?) *
I have read and agree to the Scholarship Terms and Conditions on the website ( ) *
I commit to providing feedback in the form of a monthly short survey in exchange for this service. *
I understand and agree that if I do not provide feedback as agreed to in the terms and conditions, my service will be cancelled and this service will not be offered as a scholarship for the rest of this life. *
I commit that once I begin this service I will remain on the service for at least 3 months to see how it effects my life . *
I agree to my feedback being used in any form the Company chooses. We will never disclose personal information except as agreed to below. *
I can commit the following amount per month in exchange for this service (please provide the amount below). $CDN *
I agree that I will review the amount I provide for this service every 6 months. *
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This form was created inside of Clearly Conscious Energetics.