The AMA DISC Survey
Application Form
The AMA DISC Survey
The success of every workplace is dependent on the way people complete their
work and interact with each other and customers. The challenge for most people
is to understand that others around them can be fundamentally different in their
approach to work and life.
The AMA Disc is a tool that accurately explains the strengths and weaknesses of
your team’s work related behaviour styles and strategies for building
effectiveness.
AMA DISC Survey Accreditation equips candidates with the necessary
knowledge and skills to be able to use the AMA DISC Survey competently.
The Advantages of the AMA DISC Survey;
 Specifically assess on-the-job behaviours (not general personality
preferences)

Provides insights into productive and counter-productive aspects of each
style to improve work related performance

Easy for participants to complete as the response options are on a 5 point
ranking scale

Gives confidence that the results are accurate. AMA’s DISC Survey meets
American Psychological Association & American Educational Research
Association standards for reliability and validity

Describes William Marston's D.I.S.C. framework using the basic styles of
Directing, Influencing, Supportive and Contemplative

Cost effective – the cost per person is $40 (RRP, GST inclusive)
Application Process
To become AMA Disc accredited please complete Sections 1 to 3 of this
application form and return them to Zara on the Professional Development team
either by;
Email
zara@human-synergistics.com.au
Fax:
02 9247 6310
The AMA DISC Survey
Application Form
Section 1: Administration
Individual Name: ______________________________________________
Company Name: _______________________________________________
Title:
_______________________________________________
Business Address:______________________________________________
_________________________________________Post Code:___________
Business Telephone:____________________ Facsimile:________________
Mobile Phone:
_______________________________________________
E-mail:
_______________________________________________
How were you introduced to Human Synergistics?
______________________________________________________________
______________________________________________________________
If any, what are your concerns with the Accreditation process, Human Synergistics'
products or any other aspects:
______________________________________________________________
______________________________________________________________
Professional Indemnity Insurance details:
Please provide details of your Professional Indemnity Insurance details, as your
application is contingent on these details being provided.
Professional Indemnity Insurance number:
_________________________________________
Organisation with whom you are indemnified:
_________________________________________
Amount for which you are indemnified:
_________________________________________
The AMA DISC Survey
American Management Association Copyright  2000 Center for Applied Research, Inc. All Rights Reserved
Research & Development by Robert A Cooke, Ph.D
Page 2
The AMA DISC Survey
Application Form
Section 2: Payment Details
Investment:
AMA Disc Accreditation Workshop
$1,950
Payment Method
Cheque
Please make cheque payable to Human Synergistics Australia Pty Ltd.
A tax invoice will be provided upon receipt of payment
Account
If your organisation has an existing credit account with Human Synergistics, an
invoice can be raised which needs to be paid no later than 7 days before the
commencement of the workshop.
Unsure whether you have an account? Please call us to confirm.
Electronic
How to Pay: CBA
Funds
BSB: 062 – 033
Transfer
Account: 10173222
An invoice will be provided prior to transfer as a reference
Credit Card *
Please complete authorisation below
* Please note: A 2.5% surcharge + GST applies when payment is made via credit card
Credit Card Details
Name on Card: ______________________________________
Credit Card Type:
Bankcard
Mastercard
Visa
Diners
American Express
Card Number:
_______________________________________Expiry Date:___/___
Amount:
$2003.65
(This amount includes the 2.5% credit card surcharge and GST)
I give authority for the above card to be charged by Human Synergistics Australia Pty Ltd.
_____________________________________________________________
Signature of Authorised Person
AMA Disc Accreditation Cancellations
Cancellations or postponements will be accepted up to 10 working days before the workshop and
incur a fee of $295.
The AMA DISC Survey
American Management Association Copyright  2000 Center for Applied Research, Inc. All Rights Reserved
Research & Development by Robert A Cooke, Ph.D
Page 3
The AMA DISC Survey
Application Form
Section 3: AMA Disc Accreditation Deed
This Deed is made on the ____ day of ________________ 20 __
BETWEEN:
_______________________________________________ (Name)
Of ________________________________________ (Address)
(“The Applicant”)
AND:
Human Synergistics Australia Pty Ltd
(ACN 093 428 098)
Of Suite, 2, Level 1, 8 Windmill Street MILLERS POINT NSW 2000
(“The Company”)
Definitions
Accredited Consultant/User - means an entity which has undertaken and fulfilled the
steps involved in the Company’s accreditation process, meets the requirements of the
conditions attached to that process and can demonstrate basic competence in the use of
the Company’s products.
Client – means the end user of the reports generated by the AMA DISC Measurement
Model.
Client Data – means the information the Client provides to enable report production, the
plotting of the profiles, the formulation of graphs and tables.
Materials – means the items supplied by the Company to enable the Client Data to be
collected and the format of the reports, graphs and tables.
Retraining – means a half day meeting with a representative of the Company.
Participant – means the subjects of the AMA DISC measurement model.
The AMA DISC Survey
American Management Association Copyright  2000 Center for Applied Research, Inc. All Rights Reserved
Research & Development by Robert A Cooke, Ph.D
Page 4
The AMA DISC Survey
Application Form
Operative Clauses
1.
The Materials and all rights in them are the exclusive property of the Company. The
Applicant agrees that it will not duplicate, photocopy, reproduce, rent, translate, sublicence or do any other thing with the Materials that would be inconsistent with the
Company’s exclusive ownership of the Materials.
2.
The Applicant agrees to co-operate with the Company to safeguard and not to violate
the Company's, Human Synergistics International's and Source Publishing's
intellectual property and agrees to inform the Company of any infringement by
themselves or any third party of those intellectual property rights immediately upon
becoming so aware.
3.
The Applicant agrees that appropriate attribution for ownership of intellectual property
rights, will be included on all reports, proposals, training materials and manuscripts
and all works relating to or resulting from the use of the diagnostics. The attribution
must read substantially like the following notice and appear below any major portions
of text and figures.
Reprinted with permission from American Management Association © 2000
Centre for Applied Research, Inc. Research & Development by Robert A
Cooke, Ph.D
4.
The Applicant agrees that no derivatives, modifications, alterations, variations or
additions will be made to the Materials without the express prior written permission of
the Company. The Applicant further agrees that it will not use any materials that are
not provided or authorised by the Company or intermingle the Materials with any
unauthorised materials in any presentation or demonstration.
5.
The Applicant agrees to use the Materials for development purposes only and not to
use the Materials for recruiting, promoting or terminating employees.
6.
The Company agrees to make all reasonable endeavours to train the Applicant in the
use of the Materials and to inform the Applicant of changes, updates or developments
in respect of the Materials. The Applicant acknowledges that changes, updates or
developments to the Materials may take place without prior notice.
7.
The Company agrees to supply such materials, instructor notes, computer processing
capability, video, audio tapes etc, at prevailing prices, as may be required in order
that the Applicant may be able to use the aforesaid Materials. The Applicant may
have to sign an additional license agreement for the use of computer software.
8.
The Applicant agrees not to make the Materials available for use or interpretation to
any person who has not been accredited or otherwise authorised to use the
Materials.
The AMA DISC Survey
American Management Association Copyright  2000 Center for Applied Research, Inc. All Rights Reserved
Research & Development by Robert A Cooke, Ph.D
Page 5
The AMA DISC Survey
Application Form
9.
The Applicant agrees that the Materials will be used only by the Applicant as part of
their consulting activities, that all rights and obligations arising from this Deed cannot
be assigned and that the Applicant will not act as a sub-distributor of the Materials.
10. The Applicant agrees that all information provided by participants and the subsequent
reports supplied by the Company are confidential and for the exclusive use of the
participant only and that all will be stored to maintain the confidentiality.
11. The Applicant agrees to indemnify and keep the Company indemnified against any
and all liability, loss or damage arising from and costs connected with this Deed or
any tort, including negligence, arising from misuse and/or misinterpretation and/or the
actions of the Applicant in the use of the Materials and the results.
12. The Applicant shall not represent themself as an employee or agent of the Company
and shall not obligate the Company to any contract or liability without the written
consent of a director of the Company or their authorised agent.
13. The Company agrees to make available the Materials as covered by the accreditation
program attended by the Applicant at prices outlined in the price list available from
the Company as amended from time to time. The Applicant recognises that the
Materials have been developed by professionals, using reasonable and prudent
research methods and that the Materials contain diagnostics, which, if properly used,
are reasonably expected to help individuals grow and businesses succeed.
14. The Company agrees to provide the Applicant with AMA DISC profiles, which only
the Applicant is permitted to reproduce. All copyrights must be included in any such
reproduction including but not limited to reports, power point presentations etc. The
Applicant is not permitted to modify, adjust or draw data.
15. The Applicant agrees to submit to the Company's normal quality control procedures
(of which the Applicant will be informed) and to attend Retraining when there is a
substantial change to the Materials.
16. The Applicant agrees to use only materials supplied and approved by the Company.
All and any materials devised or invented by the Applicant, or third parties for use
with the materials are to be submitted to the Company for approval.
17. The Applicant agrees to provide diagnostic inventory data to the Company to
maintain its research database.
The Company acknowledges that client
confidentially owed by the Applicant to the Applicant’s clients will be protected.
18. The Applicant agrees to use the Materials in a professional and dignified manner as
frequently as is appropriate to their needs.
19. Any Applicant who does not, after suitable training, meet the Company's quality
requirements (which is the competency assessment) shall if certified cease to be
The AMA DISC Survey
American Management Association Copyright  2000 Center for Applied Research, Inc. All Rights Reserved
Research & Development by Robert A Cooke, Ph.D
Page 6
The AMA DISC Survey
Application Form
certified as an Accredited Consultant/User. The Company may terminate this Deed if
the Applicant fails to meet the Company's quality standards or if they are in breach of
any term of this Deed.
20. This Deed is intended to safeguard the Company, the Client and the Applicant, and
shall continue in effect until terminated by either party giving the other thirty (30) days
notice in writing of its intention to terminate. The Company reserves the right to
terminate this Deed before or during the accreditation process if the Applicant fails to
meet any of their obligations in completing this process. On termination of the
agreement the Applicant agrees not to hold him or herself out as an accredited
consultation/user nor hold themselves out as being affiliated with the company.
21. The parties agree that the following provisions of this Deed survive termination,
clauses 1, 2, 4, 5, 8, 10, 12, 15 and 21.
22. The Applicant has been provided with and acknowledges receiving a schedule of
fees relating to the accreditation process specifying an amount and a time for
payment. The Applicant agrees to pay those fees to the company as and when they
fall due. In the event that the Applicant is not successful in attaining accreditation as
a consultant or user, which is determined at the absolute discretion of the company,
then any accreditation fees paid or due at that time are not refundable to the
Applicant.
EXECUTED AS A DEED
SIGNED, SEALED & DELIVERED
by :
(ACN
)
before me:
)
)
)
……………………….
…………………….
Witness
SIGNED, SEALED & DELIVERED
by Human Synergistics Pty Limited
(ACN 093 428 098)
)
before me:
)
)
……………………….
…………………….
Witness
The AMA DISC Survey
American Management Association Copyright  2000 Center for Applied Research, Inc. All Rights Reserved
Research & Development by Robert A Cooke, Ph.D
Page 7