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Appendix - Healing Touch Program

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<strong>Appendix</strong><br />

Level 1 Instructor Certification Application<br />

Application for Level 6 Training<br />

Submission Date ___________________<br />

Name _________________________________________________________________<br />

Last<br />

First<br />

Address _______________________________________________________________<br />

City ______________________________ State/Province ______________________<br />

Zip/Postal Code _____________________ Country __________________________<br />

Credentials: ________________________<br />

Include the phone number(s) and email address you want HTP to use for communication:<br />

Home Phone ________________________<br />

Home Email _________________________<br />

Cell Phone __________________________<br />

Work Phone ________________________ Work Email __________________________<br />

Please fill out and attach the Level 6 Training Application Checklist and all related materials.<br />

SEND PACKET TO:<br />

Assistant to the <strong>Program</strong> Director<br />

<strong>Healing</strong> <strong>Touch</strong> <strong>Program</strong><br />

P.O. Box 16189<br />

Golden, CO 80402<br />

Deposit information:<br />

____ Enclosed is a check or money order for $200.00<br />

____ Please charge $200.00 to my credit Card Please Circle One: VISA M/C<br />

Card Number __________________________ Expiration Date: _________<br />

Three digit safety code ________<br />

Your Signature ___________________________________<br />

Office Use Only: Auth # _____________________ CC Order #______________________<br />

© Copyright 2008 <strong>Healing</strong> <strong>Touch</strong> <strong>Program</strong> HTP-930 03.26.08<br />

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