The International Hypnosis Research Institute -- New Membership Application

New Membership Application

Join as a member, and sign up for one our our distance learning courses for free.
This is a $185 additional value.
Upon joining and receiving your invoice you will receive a link to the registration page for your free course.

Name & Address

Title

First Name *

Last Name *

Suffix

Academic Degree(s) -- Masters & above.

Designation(s) (Abbreviate recognized certifications.)

Memberships (Name or abbreviate organizations which you currently hold memberships.)

Name of company, institution, or practice

Address *

City *

State *

ZIP or Postal Code *

Country

Contact Information

Office Phone *

Fax Number

E-Mail Address *

Web Address

Qualifications
Please check each category for which you have received a training certificate, degree or license.
Please do not check any category for which you have not received adequate training or licensure for your legal jurisdiction.

Acupuncture Ayurvedic Medicine Biofeedback Chiropractic Coaching Cognitive Based Therapy (CBT) Counselor Dance/Movement Therapy Dentists	Energy Medicine Energy Psychology Homeopathy Hypnotherapy Massage Therapy Medical Doctor (Allopathic) Medical Technology Medical Administration	Music Therapy Naturopathy Neurofeedback Neurolinguistic Programming (NLP) Nursing Oriental Medicine Osteopathic Physicians Psychology	Psychotherapy Qi Gong Quantum Focus Quantum Touch Reiki Social worker Therapeutic Touch Yoga Teacher
Other

Membership Level
Please select your appropriate level of membership.
Your credit card will be charged based upon your selection.
Fees shown are payable annually.

Practitioner
      (Clinician,
      Researcher,       Instructor)
       $89 per year

Student
      (Currently enrolled
      in affiliated school or
      university and not a
      practitioner)
      $35 per year

School Code:

Retired
      (60 years old
      or older and not
      a practitioner)
      $55 per year

Corporate
      (Educational
      institution, research
      facility, or clinical
      practice. May add up
      to four more
      practitioners
      upon joining.)
      $249 per year

Additional Information
Please let us know if any of these three categories apply.

Author
      (Published books, journal
      papers, printed or on-line
      articles)

Speaker
(Professional speaker or
presented at a conference)

Trainer
      (Corporate trainer, conducts
      workshops, or conducts
      certification training)

Referral Directory Comments
For Practitioners and Corporate Members only. Please check the "Include in Referral Directory" box and include text if you wish to be added to our Referral Directory. This directory will available for the general public.

Include in Referral Directory

Your directory comments:

You have 250 remaining characters.

Credit Card
Please enter credit card information.
If you do not wish to use a credit card, please print this completed form, include your check, and mail to:

The International Hypnosis Research Institute, LLC, 2104 Del Carmen Drive, Anniston, AL 36207

Charge amount due to my credit card (AMEX / Discover / Master Card / VISA)

Card Number:	Required
Expiration Date:	Required
3 or 4 Digit Security Code (from back side of card):	Required
Name as shown on card:	Required
Billing Address:	Street Only! Required
Billing State or Province:	Required (If not applicable, write None.)
Billing ZIP (Postal) Code:	Required

I certify that I have reviewed the contents of this entire form and that my entries are correct. I understand that membership is at the sole discretion of the Institute. I attest that I will comply with the Institutes's Ethical Guidelines and agree to have my credit card charged the selected amount. All sales are final.