Application Form

Application Form Print this form and fax or mail in: Fax #: (847) 697-3309   (You can also register by phone: 847-760-5000) It is important that you register at least two weeks before the start of a class to receive your orientation materials and get you set up for the class. Early registration secures your confirmation number and a place in class. Please register me for Course #/s:________________________To be held:_______________________ Name____________________________________________________________________________                                     Print your name as you wish it to appear on your certificates. Address___________________________________________________________________________ City____________________________ State____________ Zip_______________________________ Telephone Numbers: Office__________________ Home_____________________________________ Occupation/Profession________________________________________________________________ Birth Date_____________________________ Social Security #_______________________________ Educational Background:      High School Graduate     College Graduate - List Degrees____________________________________________________ College (s) Attended_________________________________________________________________ Other Specialized  Training____________________________________________________________ ________________________________________________________________________________ _________________________________________________________________________________ I have previously practiced hypnotism since (year)_______________ Foreign languages in which I work are____________________________________________________ I plan to specialize in_________________________________________________________________ All courses carry a money back guarantee. If after the first eight hours of class time you feel you are not learning everything that you expected, you are welcome to a full and cheerful refund. It is further guaranteed that you will master the art of hypnosis by completion of the class. Enclosed is my check/money order or charge card number in the amount of $_________________ (minimum 50%). The balance is due on or before the commencement of the first day of class. Enroll and pay for all three courses in advance and receive the Success Package The Collector's Edition of "My Method" By Emile Coue," plus, Introduction to "Neurotechnology" on disk, and the audiocassette, "Accelerated Learning With hypnosis Charge Card Number:_________________________________ Exp. Date:___________________ Signature:_________________________________________________________ You can register now by phone with Visa, MasterCard or Discover: Toll Free: 866-883-9839 In Illinois: 847-760-5000