selectreg

BLOCK CAPITALS PLEASE

DATE

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

ADDRESS ( including district )

TOWN OR CITY

COUNTY

( please tick U.K. location )

ENGLAND

IRELAND

SCOTLAND

WALES

POST CODE

DATE OF BIRTH

TELEPHONE NUMBER (including area code)

MOBILE NUMBER

FAX NUMBER

E-MAIL ADDRESS

WEBSITE NAME ( If you have a site already online )

WEBSITE ADDRESS ( will be hyperlinked to your webpage if applicable )

QUALIFICATIONS

ORGANISATION MEMBERSHIPS ( please print it exactly as you want it to appear)

WEBSITE ADDRESSES

( Above organisations that have a web presence may be hyperlinked to your webpage)

Please send a digital photograph of yourself either by email or post . All documentation

is completely 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 Directory. 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

PHOTOGRAPH

650 WORDS OF WEBPAGE TEXT

( In addition to sending a ' hard copy ' of your text

please e-mail it (not as an attachment) with your name and address)

PLEASE SEND TO

THE HYPNOS PRACTICE

MEDIA DEPT.

9 SIMONSIDE

HOUGH GREEN

WIDNES

CHESHIRE WA8 4YL.