Your full name: City, state or province and country: ):

Email address (best one--that you check regularly):

CSRM session you are applying for (date of first meeting):

How long have you been a Chios Master Teacher?

Approximately how many total times have you practiced Chios Meditation (number of sessions)? 0-5 6-10 11-20 More than 20

Have you carefully read the instructions for Chios Meditation and are you confident you are practicing the technique correctly? Yes No Not Sure

How settled, comfortable and confident do you feel in your practice of Chios Meditation (scale of 1-5)? (1) Not at All (2) Somewhat (3) Average (4) Very (5) Extremely

How many Chios group meditations have you participated in?

Please choose a six digit PIN code (six numbers, no letters or symbols): Write down your PIN code and keep it in a safe place (it will be required to open your course materials).

Exact way you want your name to appear on your degree certificate: Please read the following carefully. If you agree, please sign in the space provided.

If accepted into the course I agree that, in consideration for being taught the valuable knowledge therein:

1. I will keep all knowledge and techniques taught in the course completely confidential. I will not furnish the course manual (including any future editions) or any portion of it to anyone. I will not reproduce the course manual (including any future editions) or any portion of it, the information in it or the means of practice of the techniques in it (including any future versions or additions to techniques) in any way or form, including electronic, mechanical, photocopying, audio or video recording, or in a book, article or any other form of publication, or place it into any information storage system, network or on the Internet.

2. I will use the techniques taught in the course only for the healing purposes and applications taught as part of the course, will not combine or use them with techniques from any other healing art, and will not employ them for any other purpose or use. I will use the techniques and knowledge taught only for positive, ethical and healing purposes.

3. I will not incorporate or teach any of the knowledge and techniques taught in this course into my Chios or any other teaching work unless and until authorized to do so.

Typing my full name below is my electronic signature and full agreement to the above:

Name: Date: Be sure all items above are complete. Attach saved PDF to email and send to: SuperRadiance@chioshealing.com

Your full name: City state or province and country: that you check regularly: CSRM session you are applying for date of first meeting: How long have you been a Chios Master Teacher: Approximately how many total times have you practiced Chios Meditation number of sessions: 610: 1120: More than 20: Have you carefully read the instructions for Chios Meditation and are you confident you are practicing: No: Not Sure: How settled comfortable and confident do you feel in your practice of Chios Meditation scale of 15: 2 Somewhat: 3 Average: 4 Very: 5 Extremely: How many Chios group meditations have you participated in: Please choose a six digit PIN code six numbers no letters or symbols: Exact way you want your name to appear on your degree certificate: Name: Date: