THE AMERICAN COLLEGE OF HYPNOTHERAPY
APPLICATION FOR CERTIFICATION
Application for Certification by: _____ Examination _____ Reciprocity
Application for Certification for: _____ Certified Hypnotist _____ Certified Clinical Hypnotherapist
Name:____________________________________________________________________ Date :_____________
City:____________________________________ State:_____________ Zip:____________________________
School or Educational Program Attended:_________________________________________________________
City:______________________________________________ State:_______________ Zip:_________________
Date of Completion:_________________________________ Number of hours of instruction:______________
Copy of curriculum or courses taken is attached: _____ Yes _____No
Applicants must submit one of the following: 1) a copy of their certificate of completion, or 2) an official letter by the school, educational program, or instructor verifying successful completion of the program and the number of contact hours of the educational program. Note: if the certificate of completion does not have the number of contact hours detailed on it, then it is necessary to submit an official letter from the school, program or instructor verifying the number of hours or college credits earned.
For translation purposes, the ACH uses the following conversion: 50 minutes = 1 contact hour. 1 semester unit of college credit = 15 contact hours.
Applicants must submit to the ACH a copy of the curriculum of study for the program attended. This includes course titles, and/or course descriptions. However, if the attended school or program has already been approved by the ACH, it is not necessary to submit evidence of curriculum. Check on the web site for school/program approvals.
For Applicants Applying for Reciprocity
Organization or Certifying Body you are currently certified by:_______________________________________
Date of certification:__________________________________ Date of expiration:________________________
Candidates must submit a copy of their current certification certificate or a copy of their official letter of certification by the organization or certifying body. The ACH reserves the right to contact such organization or body and verify certification of the applicant. If you are certified by more than one certifying association or body, only evidence of one is necessary. Please include the name of your educational program and city and state. It is not necessary to provide curriculum verification if you are seeking certification by reciprocity.
List all degrees/credentials earned to date: _____________________________________________________________________________________________
Method of Payment:
Application fee for 4 year term of certification is $ 200.00
_____ Money Order
_____ Credit Card _____ Visa _____ MC
Card Number:____________________________________________________ Expiration:_________________
Name on Card:___________________________________________________ Signature:___________________
I, the undersigned, verify that this application is complete, and to the best of my knowledge, all information provided is factual and true. I understand that failure to provided the needed information and required documentation could likely lead to delays in the processing of this application. I further understand that if any information supplied on this application is false, that I will be denied consideration for certification. I further understand that if at any time it is discovered that I have made false or untrue statements on this application, or misrepresented myself, or have provided fraudulent documentation to the ACH, that the ACH may rescind my certification and fellowship status.
American College Hypnotherapy
2400 Niles-Cortland Rd. SE Suite # 4
Warren Ohio 44484