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APPLICATION FOR ENROLLMENT

Name:            
Address:         
City:            
State/Country:   
Zip/Postal:      
Date of Birth:   
Occupation:      
How Long?:       
Phone (Home)):     
Phone(Work):     

Please, explain your interest in Medical Hypnosis:

Please, list any books you have read on Medical Hypnosis:

Please, Explain how you  plan to integrate this class in your practice:

Have you been hypnotized before?:

 

I understand that this course of instruction is a class participation activity. I understand that upon successful completion I will be certified by the World Institute of Cognitive Sciences, the Self-Empowerment Education Center, and the International Council for Medical and Clinical Therapists.

Please, make check or money order payable to: Self-Empowerment Education Center
For Credit Card Payment Please Enter All Necessary Information Below:
1-888-658-2014 for registration only

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Card Number:      
Expiration Date:  

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