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CERTIFICATION APPLICATION FEE FORM

Personal Information: * REQUIRED INFORMATION
*First Name:
*Last Name:
Phone Number:
Fax Number:
*Email:
Location of Evaluation:
 

By submitting this application fee I am certifying that I have completed and submitted all materials required by the Training Standards Commission for IIPA certification.  I also certify that I am a paid up member of the IIPA.
 

I am applying for certification as (check one):

Application Fee: 330 €

Payment can be made by: (please check one)


Check or Money Order:

While we will accept checks designated payable in euros, we prefer to receive international money orders for euros payable to: the International Integrative Psychotherapy Association.
Please send the check or money order to
(in Dollars) to: Wayne Carpenter • 218 Peterson Street, Suite A. • Fort Collins, Co. 80524-2986
(in Euros) to: Thierry Clugery • 117, Bd de Strasbourg 76600 LE HAVRE – France


Credit card:
VISA
Expiration Date:
  MASTERCARD Expiration Date:

Name on credit card:

Account Number:

CVVS Code: (Visa/MasterCard: 3-4 digits at the end of numbers on upper right side of signature strip.)
PLEASE CLICK THE SUBMIT BUTTON ONLY ONCE
It may take a few moments to process your order.
  
For Certification questions contact Helene Cadot at:  helene_cadot@cheerful.com