IARRT Training Course Application

Please provide all requested information. A Red Asterisk indicates required information.

GENERAL INFORMATION
Date (today's date) * / MM / DD YYYY
I am interested in taking: * Hypnosis & Introduction to Regression Therapy Level 2 - Fundamental Skills Level 3 - Intermediate Skills Level 4 - Advanced Skills & New Developments in the Field
Name * Title First Last Suffix
Name you would like to be called
Birthdate / MM / DD YYYY
Mailing Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - Home * - (###) - ### ####
Phone - Work - (###) - ### ####
Phone - Mobile - (###) - ### ####
International Phone Numbers
Primary Email Address *
DEGREES, LICENSES & CERTIFICATIONS
Profession/No. Years in that profession. *

Please give your current profession and indicate the number of years you have been in that profession.
Degrees: Show Type/Year/School. List one per line. *

Use one line for each degree/year/school combination. For example: BA/1965/CCNY MFA/1970/University of New Mexico PhD/1976/University of Arizona
Licenses: Show Type/License Number/Granting Institution. List one per line. *
Certifications: Show Type/Cert. Number/Granting Institution. List one per line. *
RELEVANT TRAINING
Have you had Hypnosis Training? * Yes No
For this and other questions requesting documentation, you can provide copies by postal mail to the address shown at the end of this form. Alternatively, if you have electronic versions of any documentation, you may also use the File Upload feature to submit these.

If you answered Yes to the previous question about Hypnosis Training, please give details including names of schools or instructors, # hours completed, and provide supporting documentation.
Upload a File
Have you had Past-Life Regression Training? * Yes No
If you answered Yes to the previous question about Past-Life Regression Training, please give details including names of schools or instructors, # hours completed, and provide supporting documentation.
Upload a File
Other Courses or Training pertinent to this IARRT Training Course: Please give names of schools, instructors, # hours completed, and provide supporting documentation. *
Upload a File
RELEVANT EXPERIENCE
No. Years doing PLR as a professional *
Type of PLR Practice Private Group Institution
Name of Institution/ No. Clients seen each week (on average)
OTHER INFORMATION
If You Are a Student, please give: Name of School/College/University? Focus of your studies?
Where did you learn of the IARRT Training Event?
TUITION
IARRT Members
All Levels: early registration $450; after deadline $550
Non-Members
All Levels: early registration $500; after deadline $600
IARRT OFFICE ADDRESS
Mail application and supporting documents to:
IARRT - Attn: Training Director
PO Box 20151
Riverside, CA 92516 USA
Tel: 951-784-1570
Fax: 951-784-8440

Following notification of placement, payment can be made online by PayPal. Or to register and pay, contact:
IARRT, PO Box 20151, Riverside, CA 92516 USA
Tel: 951-784-1570
Fax: 951-784-8440
email: pastlife@empirenet.com
website: www.IARRT.org

IARRT Training Course Application

IARRT Training Course Application

GENERAL INFORMATION

DEGREES, LICENSES & CERTIFICATIONS

RELEVANT TRAINING

RELEVANT EXPERIENCE

OTHER INFORMATION

TUITION IARRT Members All Levels: early registration $450; after deadline $550 Non-Members All Levels: early registration $500; after deadline $600

TUITION
IARRT Members
All Levels: early registration $450; after deadline $550
Non-Members
All Levels: early registration $500; after deadline $600