SurveyMonkey Powered Online Survey

**Shreem Brzee | Immersion Diamond Program Application**

Thank you for your interest in Dr. Pillai's Shreem Brzee Immersion Diamond Program. This program is for high achievers who are motivated to make big changes in their lives and help others do the same. Please answer the following application questions. Dr. Pillai will personally review your answers and you will be notified whether you have been accepted into the program.

The energy exchange for the 6-month program is a $10,000 one time fee or 6 monthly payments of $1,850. Please only apply if this energy exchange fits your budget.

We wish you all the best!
Shreem Brzee

Question Title

* 1. Please enter your full name.

Question Title

* 2. Where do you currently reside? (City, State, Country)

Question Title

* 3. Please share why you wish to join this program.

Question Title

* 4. What is your current career?

Question Title

* 5. What are your aspirations in the following areas of life:

Financial

Spiritual

Relationship

Health

Other

Question Title

* 6. What is your yearly income?

under $100,000

$101,000 - $150,000

$151,000 - $250,000

$251,000 - $350,000

$351,000 - $450,000

$451, 000 - $550,000

$551,000 - $650,000

above $650,000

Question Title

* 7. What questions do you have about this program?

Question Title

* 8. What is your birth location (City and Country)?

Question Title

* 9. What is your birth time?

Question Title

* 10. What is your date of birth?

Please select a date

Date

Question Title

* 11. Please provide your email address so we can communicate with you about next steps.

Question Title

* 12. Please provide your phone number.

If you have any questions or would like to speak with someone about this program, please contact us at programs@pillaicenter.com.