5-PATH® IAHP Board Certification Program Application

5-PATH® International Association of Professional Hypnotists
(5-PATH® IAHP)

Board Certification Application
(Fees are as follows: a $25.00 Non-Refundable Application Fee plus $250.00 Board Exam fee - Total $275.00)

By filling out this application and signing it, you are stating that all of the information is true. Your information will only be viewed by the 5-PATH® IAHP Board Certification Committee members. This information will be kept strictly confidential.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name
Address
Cell Phone
Format: (000) 000-0000.
Email Address
example@example.com
Website, If Any
Additional Education Beyond High School
Hypnosis Organizations that You Belong To
Related Professional Organizations that You Belong To
Years in Practice as a Hypnotist/Hypnotherapist
I currently see _______ (number) hypnosis clients a week.
Completed (Check one):
Date of Training

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Instructor's Name
Location of Training
Check one "Yes" or "No" below:
I am a current member of 5-PATH® IAHP in good standing.
I have seen at least 20 clients using 5-PATH® Forward and 7th Path Forward as the primary modality.
I understand that in order to become a Board Certified member. I must be able to truthfully answer "Yes" to all of the statements above.
I understand that in the event I fail my exams, there is a retake fee of $100.00.
Additional Information or Comments

5-PATH® IAHP Board Certification Application

$250.00 Board Exam fee plus $25.00 non-refundable application fee – total $275.00.

$275.00

Total

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Cardholder Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If you have questions about this application. please call our office at (469)969-2176 or toll free at (800) 965-3390.
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