PRINTABLE REGISTRATION FORM


Thought Field Therapy, Inc.
1300 Pali Hwy, Suite 204, Honolulu, Hawaii 96813




Thought Field Therapy
AUTHORIZED DIAGNOSTIC TRAINING

Registration Form

Please PRINT your name (and professional degree or license) exactly as you wish them to appear on your certificate:

Name: _______________________________________________________

Degree: _______________________________________________________

Address: _______________________________________________________

City: __________________     State: ___    Zip: _______________

Business phone: ____________________       Home phone: ____________________

Additional contact phone: ____________________

Profession:
    Social Worker
    Psychologist
    Physician
    Psychiatrist
    Nurse
    CNS
    CD Counselor
    Behavior Specialist
    Pastoral Counselor
    Other: __________________________
Dates & Locations:

_______________________________________________________

_______________________________________________________

_______________________________________________________

Please make checks payable to:

Thought Field Therapy, Inc. for $1750.00, and mail to 1300 Pali Hwy, Suite 204, Honolulu, Hawaii 96813. (Full refund within 14 days, if class is cancelled, or unable to attend.)

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