Membership Application Form Memberships run from January 1 through to December 31 of any given year. Dues are not prorated. Applicants will be advised when Membership has been approved. Please make sure to complete payment after filling in this form.Name* First Last Email* Address*Postal Code*Phone*Mailing Address (if different from above)Postal CodeHighest Professional Degree earned*This Degree was earned from what Educational Body?*Year of Graduation*If membership is granted, the other Degrees I would like listed in the Society Directory are:(Please use abbreviations only)I am licensed or certified in British Columbia as a:*SelectPhysicianDentistPsychologistRegistered Clinical Counsellor (BCACC)Certified Clinical Counsellor (CCPA)Social WorkerNurseMarriage & Family TherapistOtherEnter Other:License or Registration #:*I have completed my basic training in clinical hypnosis*YesNoSponsoring Organization*Place/Date*Number of Hours*Please submit a certificate of attendance with your application. If you have not completed basic training, you will be required to do so within one year of approval of your membership application. Please see Membership Eligibility for particulars of training requirements.Documentation of introductory workshopAccepted file types: pdf, jpg, gif, png, doc, docx.If applying for student membership, proof of student statusAccepted file types: pdf, jpg, gif, png, doc, docx.I am a member of the American Society of Clinical Hypnosis*YesNo*** Please note that only Full members will be listed as accepting referrals.If Full membership is granted, do you plan to accept referrals?*YesNoPlease indicate what areas you will be offering treatment*If Full membership is granted, would you like your information listed on our website for referrals?*YesNoWould you like your website address linked with our website?*YesNoYour Website address*Referred byDo you have or have you had any restrictions, reprimands, or ongoing disciplinary investigation being conducted by your regulatory body regarding your licensure of registration?*YesNoPlease explain*Certification* I certify that the above information is complete and accurate. Method of Payment*Credit CardInterac e-TransferMembership will only be accepted on completion of payment.