Membership Renewal Form Before completing this form please check your existing listing on the "Find a Hypnotherapist" page (see above) so you are aware of which details, if any, need to be changed. Name on Certificate*NZHRB Registration Number -* This is on your Annual Practicing Certificate and Registration CertificateEmail* Do you want your contact details listed on the NZHRB Web Site?*YesNoDo you require the insurance code?*YesNoON-GOING TRAINING / PROFESSIONAL DEVELOPMENTTo maintain your registration a minimum of 15 hours Professional Development / Ongoing Training per annum is required. Please list details of PD/OT completed - sufficient to cover the 15 hours, since 1st April last year, including the number of hours of each. NOTE: We do not require ALL PH/OT to be listed if more than 15 hours. Ongoing Training / Professional Development*In certain circumstances (E.g. serious illness, financial hardship) the board has the ability to waive the renewal fee and/or continuing education requirements, on a case by case basis. If you find yourself in this situation please contact the board. Have you had any criminal convictions since joining the NZHRB?*Yes - Please detail belowNoList all criminal convictions since joining the NZHRB:LEGAL: By completing this form you declare that the information given is a true and accurate record. ANNUAL RENEWALPaid BY 31st March Price: $ 60.00 Quantity: Paid FROM 1st April Price: $ 66.00 Quantity: Total $ 0.00 I am making this payment by:*Internet Banking -Cheque payable to NZHRBPlease make a note of the account for payment: NZHRB 010154 - 0183700-00 Date Paid* If paying by internet banking please take note of the following bank account details: Account: NZHRB Account No: 010154 0183700-00 Please put your name and registration number as a references. CHANGE DETAILSHave any contact details changed since last renewal?*YesNoONLY complete details in this section if any contact details has been changed since last renewal.Change Business / Clinic Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Change Postal Address (if different) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Change Home PhoneChange Mobile PhoneChange Business PhoneChange Web Site Address Any other changes?