Name: _______________________________________________________

Agency: _______________________________________________________

Address: ______________________________________________________

Postal Code: ___________________

Telephone: (______)___________________

Education: ____________________________________________________

Current Position and Duties: ____________________________________________________________

___________________________________________________________________________________

Related Experience: __________________________________________________________________

___________________________________________________________________________________

Current Supervisor: _____________________________

Telephone: (____)_______________

Attach Work Sample : (Include one DISC Record Form with all identifying information deleted except for the child's age; all 3 Summary sheets; brief summary report re: child's history, observation during screening session, interpretation of results, referrals or programming strategies.) A report outline for the DISC is available on the DISC website.

Total # of DISC Screenings Completed to Date: ______ A minimum of 10 DISC administrations is advised before submitting a work sample.

Have you attended a Level II DISC Training Workshop? No: ___ Yes: ___
Date: ____________

If No, please enclose a cheque for ($50. + $6.50 HST - 13%) $56.50 for marking.

Please return this application and work sample to:

Marian Mainland
Mainland Consulting, Inc.
4 Danube Drive
Heidelberg, Ontario
Canada NOB 1YO
(519) 699-5429
FAX: (519) 699-4890