Membership Application

*Title
*Your Forename
*Your Surname
*Date of Birth (dd/mm/yyyy)
/ /
*Address 1
Address 2
*City
*District / State
*Country
*Postal / Zip Code
Telephone
Fax
Email
Web Address
**Your Trainer's Details
**Qualifications & Memberships and Insurance Certificate Details
Supervision Details
*Length of Time in Practice
Any Specialised Areas

* Required Fields

** Please note that applications without trainer's details and/or details of qualifications, memberships and professional indemnity insurance certificate details (company and certificate number) will not be processed. Acceptance to Membership is not automatic and is dependent in part upon your training. If your application is accepted, we will request payment of your Annual subscription (£80.00 as at January 2016). We will send you a payment link that allows you to pay online via WorldPay, or you may send us a cheque if you prefer.



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OFFICES

United Kingdom
Telephone: 01702 347691

or email: admin@aphp.net


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