Membership Application
Hypnosis Education Association, Inc.

Print exactly as you want your name to appear on your credentials

Name ____________________________________  Home Phone ______________________

Address  ___________________________________________________________________

City ________________________________________  State ___________  Zip ___________

Occupation/Profession  _________________________________________________________

Business Name & Address  ______________________________________________________

__________________________________________ Business Phone _____________________

Email Address _____________________________

Education

High School Graduate  _____  College Graduate _____   Degrees __________________________

College(s) Attended _____________________________________________________________

Hypnosis Training (if any) _________________________________________________________
(Non-professionals are welcome - anyone interested in what hypnosis is, how it works, or what it can do.)

How did you hear about the Hypnosis Education Association ?  ____________________________

Name or nickname you prefer your friends to use  _________________________

Signed  _____________________________________ Date _____________________________

Annual dues  $50 -  Enclosed  $ ________________

Make check payable to Hypnosis Education Association, Inc.  (or to HEA)
Mail to HEA, 36181 East Lake Road  #221, Palm Harbor,  FL 34685