Practitioner Index Request Form

Back to Contents Page

Print a printer friendly version of this page

Practitioners & students studying their modality can have their details listed:
$10.00 per modality for 12 months registration.

Please fill in the following form and hit the SUBMIT button below to apply. If successful an electronic Invoice will be emailed to your email address. Please print the invoice and include it with your payment and copies of qualifications when posting them.

HOLISTIC MODALITY DIRECTORY PRACTITIONER’S INDEX REGISTRATION FORM

Fields marked with a * must be filled in
	Name:	*
	Business Name:	*
	Suburb(s):	*
	Full Address (optional):
	Modality(s) you wish to be listed under:	*
	Contact Number(s):	*
	Web Address (optional):
	Email Address:	*

In filling out and submitting this form you are also agreeing to the following understandings:
1/ All information submitted is true and
2/ All qualifications forwarded with payment have been obtained by the person who is making this application and
3/ That you work with the highest intent within your nominated modality and not work in a manner that brings the modality and therefore its other Practitioner’s into disrepute and
4/ That the Authors of the Website have the final determination as to whether these details are displayed on the website

If you wish to email your request instead, please follow the above requirements and email to: directorylistingrequest@equinoxholisticservices.com

R
E
G
I
S
T
E
R