TM

TM

REQUEST FOR ANALYSIS
No.

Dated ...............................

I hereby declare that I have understood the concept and process of Dermatoglyphics Multiple Intelligence Analysis (DMIA) for the purpose of generating Dermatoglyphics Multiple Intelligence Analysis Report. I am also consciously aware of the fact that this test requires my Fingerprints or Fingerprints of the Minor for whom I am the parent / guardian. I further declare that I am aware of the fact that the Digital Fingerprints will be taken with the help of biometric scanner. I am aware that the fingerprints will be utilized to generate mine or my ward's MI Report based on DMIA. I declare that the fingerprints can be / may be used for the Study/Studies /
Research / Researches of DMIA only, which can / may be done in future.

HAVING SAID THE ABOVE, I HEREBY GIVE MY CONSCIOUS CONSENT TO TAKE MINE OR THE MINOR'S FINGERPRINTS;
Name: _________________________________________________________________________________________________________________________________
Gender:

o Male o Female

Date of Birth: ____________________________ Age: _________________ Class _____________________

School / Institute: _____________________________________________________________________________________________________________________
Father / Guardian Name: ______________________________________________________________________________________________________________
Mobile: ________________________________________________________________________ Email: _________________________________________________
Residence Address: ____________________________________________________________________________________________________________________
City: _______________________________________________ State: ______________________________________ Pin: __________________________________

________________________________
Signature of Parent / Guardian

_____________________________
Signatur e of Applicant

DISCLAIMER: By applying for this report, you are providing your fingerprints voluntarily and in the case of minor you are representing the minor as a parent/ guardian and giving the minor's fingerprints for analysis. It's understood that given fingerprint data is analyzed/processed only for getting the final output in the form of Dermatoglyphics Multiple Intelligence Analysis Report, which is presented here. It is also informed to the consumer/person concern/guardian that the analysis and contents of this report are only references based on scientific research