Therapisits registration form Please fill out this form if you are planning to book a space in our centre Therapist Registration Form Personal DetailsName(Required) Forename Surname DOB(Required) DD slash MM slash YYYY Occupation(Required) Address(Required) Address Town Post Code Phone(Required)FaxEmail(Required) Website Professional QualificationsQualification(Required) Year(Required) Training Body(Required) Address(Required) Address Town Post Code Phone(Required)FaxEmail(Required) Membership Reg No:(Required) Exp. Date(Required) MM slash DD slash YYYY Professional QualificationsName Address Address Town Post Code PhoneFaxEmail Membership Reg No: Exp. Date DD slash MM slash YYYY Certificate of InsurancePractitioners are required to have their own professional insurance. Please give details of this below.Name(Required) Address(Required) Address Town Post Code Phone(Required)FaxEmail(Required) Membership Reg No:(Required) Exp. Date(Required) MM slash DD slash YYYY Other Qualification(s)Qualification Date MM slash DD slash YYYY Cert No. Copy Qualification Date MM slash DD slash YYYY Cert No. Copy Qualification Date MM slash DD slash YYYY Cert No. Copy Do you have any previous criminal convictions?(Required) YES NO If you have any previous criminal convictions, please give details below(Required)ReferencePlease provide the name, address and telephone number of a referee. This person must be someone that knows you in a professional capacity.Title Name(Required) Forename Surname Occupation(Required) Address(Required) Address Post Code Phone(Required)Email(Required) Website Work ExperienceTell us about your work experience pleaseDeclaration(Required)1. I agree to practice in Samye Foundation Wales Offices/Training Rooms at 250 Cowbridge Road east, Cardiff, CF5 1GZ only the registered and approved healing methods set out by my professional body and confirm the above information is correct and complete. 2. I agree to giving Samye Foundation Wales one month’s notice when I wish to terminate the hire of the premises. 3. I agree to comply with and provide a copy of all Codes of Conduct issued by my Professional Body while practising, instructing or lecturing in the building at Samye Foundation Wales, Cardiff. 4. I agree to Samye Foundation Wales conducting a Criminal Records Bureau check I agree to the following declaration
