Fellowship Application

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Please provide the following information:

Personal Information

First Name

Middle Name

Last Name

Credentials

Email Address

Years of Consecutive Paid ASCH Membership

Home Address

Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone

Mobile

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Evaluation

Please upload the following documents:

Evidence of successful use of hypnosis in clinical practice or research.
Copies of papers relating to hypnosis published by you in recognized professional journals
Documentation of your teaching of organized courses in hypnosis in recognized professional schools and/or professional societies.
Evidence of participation as an officer or committee member of ASCH, or other organizational utilization of hypnosis (publicity, publications, national or international recognition, organizing component societies, etc.)

Click or drag files to this area to upload. You can upload up to 25 files.

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Referral Information

Please list three (3) persons, other than persons who nominated you, who may be contacted for a confidential evaluation of your ethical and professional status.

Ref. 1 Name

Ref. 1 Degree

Ref. 1 Phone

Ref. 1 Email

Ref. 2 Name

Ref. 2 Degree

Ref. 2 Phone

Ref. 2 Email

Ref. 3 Name

Ref. 3 Degree

Ref. 3 Phone

Ref. 3 Email

Attestations

This application and the requested material are agreed to be dealt with as completely confidential in nature by the ASCH National Office, the appropriate reviewing parties, and the candidate. I attest to the following:

The information provide in this application is accurate and complete.