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Institute Membership Application Registration Form

This form is for applicants who would prefer to pay by cheque or postal order.


Complete the form and click 'Send Form' - then post your subscription payment, (include a note with your name and the date you
completed this registration form) to: The Institute For Reality Therapy UK, PO Box 227, Billingshurst, West Sussex, RH14 0YU

All cheques should be made payable to The Institute For Reality Therapy UK

Full Name:
   
Address:
(Please include Post Code)
Tel:
       Ext.
E-mail Address:
       Retype Email Address: A value is required.The values don't match.
Website URL:
Website log in set-up:
 
What username would you like to use - there should be no capital letters or spaces in your username
What Password would you like to use -
 
 

Please indicate
if you are:
     Counsellor [style ]         Teacher/Educator            Psychologist
     If other please indicate
Please tell us if you have had any Reality Therapy training   

Other relevant information you would like included: [maximum 150 words]
Membership Type:
     
General Membership @ £25.00 per year
Corporate For organisations with 5 + employees @ £120.00 per year
 
Coupon Code:
- (if you have one from an advertisment or special offer)
 
My cheque/postal order will be sent to the Institute on: (dd/mm/yyyy)
 
Payment must be received by the Institute before your membership is activated
All cheques should be made payable to The Institute For Reality Therapy UK
Please read carefully:

By submitting this form you are giving permission for the Institute for Reality Therapy UK to include your details on our website members secure area. You must contact the administrator directly for your listing to be removed.

 
I have read the above and undertand that my contact details will be available in the members area only Please tick.
 
 
     

 

On-Line Membership Application Form - © Institute For Reality Therapy UK 2006