TRAIN THE TRAINER INTAKE FORM

Candidate's Name

Address: City, State, Zip/PostCode, Country

Office phone number

Cell/Mobile number

Home phone number

EMail

example@example.com

Website

Earned Hypnotism Certifications - CH, BCH etc : Please provide details

Earned Hypnotism Certifications - When received (month & year)

Your Hypnotism Instructor

The Hypnotism Organisation where you trained

Certified member of NGH since (Month /Year)

Other hypnotism organizations of which you are a member

YESNO

If you've been removed from a hypnotism organisation please provide details

YesNo

if you've taught for any organisation, please provide details

How long have you been practicing hypnotism part-time?

How long have you been practicing hypnotism full-time?

Average Number of Client Hours (Doing Hypnosis) Per Week for past 12 months

Reason for wanting to take this training

Why do you think you would make a good trainer?

Academic Background

Teaching or Training Background

Describe your training in hypnotism

Have you ever been published? (hypnotism or other related field) Provide details

What are your short term goals?

What are your long term goals?

YesNo

In which State/Country do you intend to teach?

YesNo

Are you aware of any local laws regarding establishing a training school?

If there is such a requirement, when do you intend to acquire the license or other designation (ie. registration or approval)?

When do you expect to begin offering certification courses and how frequently do you expect to offer them?

Chapter meetingsSolid GoldNGH Convention

Additional information NGH should take into consideration

I declare that the above information and all material enclosed with this application is correct. I confirm that no disciplinary action is pending or has ever been sustained against me by any professional body. I further confirm that I have never been convicted of a criminal offence and that no criminal prosecution is pending.

Applicant's signature

Date