BLOCK CAPITALS PLEASE
DATE


FULL NAME ( followed by your name as you want it to appear - e.g. Mike for Michael - Pam for Pamela )


ADDRESS ( including district )


TOWN OR CITY


COUNTY


( please tick U.K. location )
ENGLAND
IRELAND
SCOTLAND
WALES

POST CODE


ADDRESS ( As you want it to appear in listing )
( If you work from home you may not want your full address shown )


DATE OF BIRTH


TELEPHONE NUMBER (including area code)


FAX NUMBER


E-MAIL ADDRESS


WEBSITE NAME and WEBSITE ADDRESS


QUALIFICATIONS





All documentation is completely confidential and will not be released to any third party.



DATE OF YOUR FIRST STANDING ORDER PAYMENT. ( either the 1st - 8th - 15th or 22nd of the month )


DECLARATION I am a fully qualified Hypnotherapist with current practice insurance, which will remain
current whilst a member of this index. I Declare that no disciplinary action has ever been taken against
me by any professional body and that no such action is currently pending. I Have read the Disclaimer
and the Terms and Conditions and I agree to be bound by them.

SIGNATURE



CHECKLIST OF DOCUMENTS TO BE ENCLOSED FOR PROCESSING OF YOUR APPLICATION

REGISTRATION FORM
S. O. BANK MANDATE

PLEASE SEND TO

THE HYPNOS PRACTICE
MEDIA DEPT.
9 SIMONSIDE
HOUGH GREEN
WIDNES
CHESHIRE WA8 4YL.


REGISTRATION FORM
We are registered with the Data Protection Agency All documentation and
unpublished information is completely confidential and will not be released to
any third party