PLEASE PRINT OUT AND COMPLETE THIS FORM

Student Application - NLP Practitioner



PLEASE BE SURE TO COMPLETE THE WHOLE FORM!


PART ONE



Date of application:..............................

Name: Mr/Mrs/Miss (or other title) ....................................................................................................................

Address:............................................................................................................................................................

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Postcode:................................. Telephone:..................................................... FAX: .........................................

Email:...............................................................................

Nationality:........................................... Marital Status:.................................. Date of birth:....../......./......


Have you any previous training or experience in any form of psychotherapy? If 'yes', please give brief details:

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Do you intend to go into practice as a therapist? (Yes/No/Maybe).......................................................

If 'Yes' do you intend to be (please indicate): (a) Full Time; (b) Part Time; (c) See how it goes

Current Occupation:.......................................................................................................................................................

Hobbies:........................................................................................................................................................................

Have you had, or do you have, any serious illnesses (including psychiatric/emotional)? If 'Yes', please give brief details here:

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What other subjects have you studied as an adult (whether or not you achieved any awards)?

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PART TWO


How do you wish to pay?

[    ] In advance (&pound640.00)

[    ] Per Lesson (&pound80.00 per lesson - 8 lessons)

I have enclosed payment of: £                     by cheque/bank draft (make cheques payable to �EICH�)

I�ll pay by credit card, number:........................................................................................Expiry:...../......

Issue number (Switch cards):........

[    ] I�m paying by monthly instalments, so please debit my credit card appropriately each month until the course is complete or until I instruct you otherwise.

I understand that purchase of one lesson/module places me under no obligation to purchase any further lessons. I also understand that if I am not accepted as a student for any reason whatsoever, any money I have paid will be refunded in full.

Signature:................................................................................

Please submit completed form to:

The Essex Institute of Clinical Hypnosis
Essex House, Clarence Road, Southend on Sea, Essex, SS1 1AN, ENGLAND
FAX: +44 (0)1702 434432 Tel: +44 (0)1702 434431 email: EICH@eich.co.uk