Application for Membership

Associate Members are eligible for Full Membership of the Society upon satisfactory completion of approved training and examinations.

Please complete all details and print this form.
The form should then be signed and returned along with accompanying documentation to the Secretary in your State Branch.

TITLE (Prof. Dr. Mr. Mrs. etc):
DATE OF APPLICATION:
GIVEN NAMES:
SURNAME:
POSTAL ADDRESS:
 
SUBURB:
POSTCODE:
   
BUSINESS ADDRESS:
 
SUBURB:
POST CODE:
 
TELEPHONE:
(Business)
TELEPHONE:
(After hours)
PROFESSION:
(Dentistry, Medicine, Psychology)
 

TRAINING:
(Please give degrees granted, University, and date of conferral)

 

DETAIL OF INITIAL REGISTRATION:

Date:
State:
Country:
(If relevant)
 

SPECIALITY (if any):

 

SUMMARY OF POST-GRADUATE EXPERIENCE (in chronological order):

 

PRESENT STATUS AND WORK AFFILIATIONS:

Private Practice: Full-Time
Part-time: no of Part-time hours
Affiliations (hospitals, etc)
Academic Appointments
Other (please specify)
 

MEMBERSHIP OF OTHER PROFESSIONAL SOCIETIES:

Australian Medical Association
Australian Dental Association
Australian Psychological Society
Other (please name)
 

PREVIOUS TRAINING, EXPERIENCE OR PUBLICATIONS IN HYPNOSIS:

 

REFEREES:
The names, addresses & signatures of two members of this Society, on eof whom is a member of your own discipline, who have agreed to support your application.

 

HUSBAND and WIFE MEMBERSHIP:
(If you wish to claim a reduced subscription for husband and wife membership, give the name of your spouse)

 

I hereby undertake and agree that if accepted for membership I will abide by the Articles, By-Laws and Code of Ethics of the Australian Society of Hypnosis Ltd. with particular reference to Guideline 3 of the Code of Ethics which is that "Each member of ASH shall limit the clinical and scientific use of hypnosis to the area of competence as defined by professional standards of his or her field."

SIGNATURE OF APPLICANT:
DATE:

PLEASE ENCLOSE WITH THIS APPLICATION:

1. Photocopy of qualifications
2. Photocopy of current professional registration (if relevant)
3. Cheque for $143.00 (SA $154.00) made payable to The Australian Society of Hypnosis

AND POST TO THE STATE SECRETARY:

FULL/ASSOCIATE MEMBERSHIP RECOMMENDED BY BRANCH EXECUTIVE/ASSOCIATE ON:

End of Application Form