standardreg

BLOCK CAPITALS PLEASE

DATE

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

FULL 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

MOBILE NUMBER

E-MAIL ADDRESS ( if applicable )

WEBSITE ADDRESS ( if applicable )

QUALIFICATIONS

MEMBERSHIPS

TREATMENTS ( you may wish to put 'All General Problems including ' plus you may nominate 6 treatments. )

SPECIALITIES ( you may nominate 2 )

FEES

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

PLEASE SEND TO

THE HYPNOS PRACTICE

MEDIA DEPT.

9 SIMONSIDE

HOUGH GREEN

WIDNES

CHESHIRE WA8 4YL