Name

Street Address
Home Phone
Cell Phone
E-mail (required)

Related experience or other healing modalities.

Date of Birth

Present Occupation

Method of payment:  Master Card Visa    Cheque   Cash

Note: Credit Card number and expiry date will be accepted by phone at 403-816-2671  or in person.

Please mail all cheques to

Calgary Hypnosis Academy

202 Hawktree Bay N.W.

Calgary Ab. T3G 2Z3

If you have you ever been convicted of a Criminal Code offence, please contact us directly by phone 403-816-2671 for consultation

I, the undersigned, verify that this application is complete, and to the best of my knowledge, all information provided is factual and true. I understand that failure to provided the needed information and required documentation could likely lead to delays in the processing of this application. I further understand that if any information supplied on this application is false, that I will be denied consideration for certification. I further understand that if at any time it is discovered that I have made false or untrue statements on this application, or misrepresented myself to the Calgary Hypnosis Academy (CHA) and the National Guild of Hypnotists (NGH) that the NGH will be notified and may rescind my certification status.