The PATH Foundation

APPLICATION / REGISTRATION FORM

Cell Command Therapy Video Hypnosis Training
The PATH Foundation, Birmingham, Alabama

Applicant's     (first name,   Middle Initial,   last name )
Name:
Address:
City , State: , zip:
Tele:(eve.) (day) (cell)
E-Mail: Website:
Occup: Employer:
Employer Address:
Sex: M: F: Age: BirthDate: Marital status:
Referred by: - Internet,  Mail Ad,  T.V. Ad,  Friend

- - College (Degree/s) Completed: Y N
- - Major(s):- - - - - - - - - - Degree - - - - - - - Yr: - - - - School & Location:



- - Hypnosis / Hypnotherapy Training Completed; Y N
- - Course: - - - - - - - - - - -School: - - - - - - # Hrs - - - - - - - Location



- - Hypnosis / Hypnotherapy Certification Completed: Y N
- - - - - Agency - - - - - - - - - - - - - - - - - Location - - - - - - - - - - - Year:

Register me for the following course(s) in DVD video home training
- - - ( CourseTitle:) - - - - - - - (Series) - - - - - - - - - - - - (amt to chg)
HYP# Course fee:$395.00
HYP# Course fee:$395.00

Please charge my credit/debit card for $395 for each course above
Card Type: - Visa  Mastercard  Discover  AmExp
Card No.: Expiration date: Mo. Yr.

Signature:___________________________________Date:_________

Include charge data above or Enclose a money order or deposit check
for $395 for each course payable to: The PATH Foundation

Mail a signed, printed copy of this form with deposit to: The PATH Foundation
1207 18th Avenue South, Birmingham, Alabama 35205
(or)    Fax this completed form to fax # 205-933-5554