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registration form

HOME> Professional Training> registration form

Copy and paste the form below into an email and then fill out and send.
(copy by clicking and dragging across the form from top to bottom.)

Registration for Professional Emotional Clearing Facilitator Certification

Name (As you want it to appear on your certificate):


Phone: Work & Home:


Date of Birth:

Current Profession including Website if have:


How do you envision using your Certification?


Other Professional Credentials / Relevant Life Experience (not req'd for cert.):


Anything Else:


Please attach a recent headshot or link to a web / FaceBook page showing a photo.



email to:
Put EC TRAINING in the email subject line


© 2004 John Ruskan / The Institute for Emotional Clearing