New Orleans Society of Clinical Hypnosis 

 

APPLICATION FOR MEMBERSHIP



NAME__________________________________ DATE_____________

I prefer that all correspondence from the society be sent to my [ ] home address [ ] business address. The applicant may fill out one or both areas of information.

HOME ADDRESS__________________________________________________________

Street

City

Zip Code

HOME PHONE________________________ HOME FAX___________________________

BUSINESS ADDRESS________________________________________________________
 Street City Zip Code

BUSINESS PHONE _______________________ BUSINESS FAX________________________

E-MAIL ADDRESS __________________________________________________

********************************************************************************************************

PRESENT POSITION_________________________________________________________

SPONSOR (Member of Society)________________________________________________________

EDUCATIONAL BACKGROUND

INSTITUTION DEGREE DATE

____________________________ _____________________________ ______________


____________________________ _____________________________ ______________

SPECIALTY: __________________________________________________________________

PROFESSIONAL AFFILIATIONS: _____________________________________________________________
__________________________________________________________________

TRAINING IN HYPNOSIS:_______________________________________________________
____________________________________________________________________________

EXPERIENCE IN THE USE OF HYPNOSIS: ____________________________________________________
_________________________________________________________________________________



Please print out this application, fill it out and bring it to a NOSCH meeting. We will be happy to meet you and look over your application at that time. You may also mail the application to our secretary:


Dov Glazer, DDS, ABHD
3525 Prytania Street, Suite 312
New Orleans, LA 70115

Office: 504.895.1137
Fax: 504.897.8010

Email: glazer@nosch.org