Membership Application Form


All fees are refundable if the application is not accepted. Please fill out the following form completely.

Note: Bold fields represent required information

Choose a Membership:
Choose a Certificate (please consult the NGH Law Guide for assistance):
First Name:
*Last Name:
Gender
Valid Email Address:
Website Address:
Phone:
Fax:
Street:
City:
State/Province:
Zip Code/Postal Code:
Country/Region:
Date of Birth:
Total Training Hours:
(Please note the NGH requires a minimum of 100 hours of training for certification - Distance learning programs will not be accepted for Certified Membership, however you may apply for Non-Certified Regular Membership - Regular members can apply to upgrade their membership after 6 months with further training)
Occupation or Profession:
I am already Certified by (Organization/School/Instructor):
Have you ever been convicted of a felony:
If you answered "Yes" above, please explain:
Have you ever been dismissed from any professional organization because of an ethics complaint?:
If you answered "Yes" above, please explain:
Highest Level of Education
Degrees attained:
Universities/Colleges Attended:
Practiced Hypnotism since (mm/dd/yyyy):
Practice Type:
Hypnotism Training School and Instructor:
*Credit Card Type
Card Holder Name:
Credit Card Number:
Expiration Date (MM/YY):
CVV Code:
The CVV Number ("Card Verification Value") on your credit card or debit card is a 3 digit number on VISA®, MasterCard® and Discover® branded credit and debit cards. On your American Express® branded credit or debit card it is a 4 digit numeric code.
If your credit card billing address is different from the one supplied above, please list it here:

The NGH requires an official photo ID (driver's license/passport) faxed, sent, or e-mailed to the NGH office in order to facilitate the application

National Guild of Hypnotists, Inc. PO Box 308 Merrimack, NH 03054-0308 FAX- 603-424-8066 E-mail - ngh@ngh.net

Honesty, Honor, Integrity: It is hereby agreed and understood that, if at any time, the National Guild of Hypnotists becomes aware of any false or misleading statements in this application, the NGH has the right to immediately revoke membership privileges and pursue any and all legal action pertaining thereto, at the sole option of the NGH.

By downloading and submitting the NGH electronic forms, you agree that: all information provided is true, correct, and complete. The NGH has your permission to verify the information reported by obtaining documentation as needed; and you understand that any incomplete, inaccurate, or otherwise false information or authenticity will delay the NGH Membership review process.

Please fill out this section with the characters provided:
Please fill out this section with the characters provided: