PLEASE PRINT OUT AND COMPLETE THIS FORM
Student Application - NLP Practitioner
Please submit completed form to:
PLEASE BE SURE TO COMPLETE THE WHOLE FORM!
PART ONE
Date of application:..............................
Name: Mr/Mrs/Miss (or other title) ....................................................................................................................
Address:............................................................................................................................................................
..........................................................................................................................................................................
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:
.......................................................................................................................................................................................
.......................................................................................................................................................................................
.......................................................................................................................................................................................
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:
......................................................................................................................................................................................
......................................................................................................................................................................................
......................................................................................................................................................................................
What other subjects have you studied as an adult (whether or not you achieved any awards)?
......................................................................................................................................................................................
......................................................................................................................................................................................
PART TWO
How do you wish to pay?
[
] In advance (£640.00)
[
] Per Lesson (£80.00 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:................................................................................