NGH Application

All questions are required unless marked optional.

About you

Name

First name

Last name

Middle initial (optional)

Your name as you want it to appear on your certificate

Date of birth

Contact information

Address

Street address

Apartment, suite, etc. (optional)

City

State / Province

Postal / Zip code

Phone number

Area code

Phone number

Reference #1

Please provide 2 professional references that we may contact to vouch for your capabilities and ethical intent. Supervisors, employees, teachers, counselors, ministers, hypnotherapists, etc are acceptable. Please do not use family as references.

Name

First name

Last name

Phone number

Area code

Phone number

Address

Street address

Apartment, suite, etc. (optional)

City

State / Province

Postal / Zip code

How do you know them?

Reference #2

Name

First name

Last name

Phone number

Area code

Phone number

Address

Street address

Apartment, suite, etc. (optional)

City

State / Province

Postal / Zip code

How do you know them?

Education and experience

In what field or major?

Current occupation

Briefly describe any experience or training you have had in hypnosis

Reason for enrolling into this course?

Final questions

How did you learn of our program?

Have you ever been convicted of a felony or sexual crime? If yes, please explain.