Course On-line Application Form

Hypnosis Course On-line Application Form

Full Name*

First NameLast Name

Age

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Home Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

E-mail*

Related experience or other healing modalities.

Present Occupation

Method of Payment:

Master CardVisaChequeCash

Note: Course fees and retainer/deposit can be paid with E-bank transfer at adhypcal@telus.net or Visa or MasterCard number and expiry date. Credit card numbers will be accepted by email, text or phone at 403-816-2671 or in person. If paying be cheque please mail or deliver to;

Please mail all cheques to:

Calgary Hypnosis Academy

202 Hawktree Bay N.W.

Calgary, AB, T3G 2Z3

If you have ever been convicted of a Criminal Code Offence, please contact us directly by phone 403-816-2671 for consultation.

I, the undersigned, verify that this application is complete, and to the best of my knowledge, all information provided is factual and true. I understand that failure to provide the needed information and required documentation could likely lead to delays in the processing of this application. I further understand that if any information supplied is false, that I will be denied consideration for certification. I further understand that if any time it is discovered that I have made false or untrue statements on this application, or misrepresented myself to the Calgary Hypnosis Academy (CHA) and the National Guild of Hypnotists (NGH) that the (NGH) will be notified and may rescind my certification status.

With above statement please choose if you agree or disagree.

I agreeI disagree