ANNHTM Registration

Use this form to submit your payment of $1299.00, which will allow you to immediately enroll
in the remainder of the required courses.
Optionally, you may pay your tuition in four monthly installments of $389.70
Charge $389.70 for four months.

This form applies only to the distance learning option.
For live course enrollment, please contact the course sponsor.

Are you an IHRI member? Members receive a discount of up to $408. (Join before submitting this application and save.) If you have a current IHRI member number,
Enter your member number here and click on BEFORE completing this form.

Name & Address
First Name *
Last Name *
Name of company, institution, or practice
Address *
City *
State *
ZIP or Postal Code *

Contact Information
Office Phone *
Fax Number
E-Mail Address *

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):
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, that I understand the requirements of the course, and the IHRI refund policy as well as my credit card will be charged the above amount.

Note: Once you have completed your payment, to enroll in a certification course you must log into your student account and use the Certification Progress Report page.
All charges are processed by The International Hypnosis Research Institute, LLC. This will appear on your credit card or bank statement.
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