7/21/2019 ECIP Application

http://slidepdf.com/reader/full/ecip-application 1/2

EUROPEAN ASSOCIATION FOR  INTEGRATIVE PSYCHOTHERAPY

European Certificate of Integrative PsychotherapyApplication Form

Section 1 (to be completed by the individual applicant)

In order to be awarded the European Certificate of Integrative Psychotherapy (hereafter ECIP) and register your contact details on the EAIP website you must sign the following statement:

I, (print name in capital letters)

agree to the EAIP egistrar holding the information that I provide below on their computer database! I also declarethat the information I give below is correct and accurate!

"igned #ate

$ow please print in capital letters the contact information below

$ame

 Address (please indicate the address you wish to have listed on the EAIP website)

%elephone

Email address

&ebsite (if applicable)

Please note, and  the category for which you wish to register:

• if registering as an Integrative Psychotherapist the initial fee is 75 euro  

• if registering as an Integrative Psychotherapist and Supervisor  the fee is 85 euro  

• If registering as an Integrative Psychotherapist Supervisor and !rainer  the fee is "5 euro  

Section # (to be completed by the sponsoring EAIP 'ember rganisation)

%he person completing this section must be authorised to do so by the 'ember rganisation (') and will normallybe the senior trainer or #irector of the '!

Person being sponsored for ECIP (print name in capital letters)

I confirm that the a$ove named person is $y the rules of my %em$er &rganisation suita$le for 

• the a'ard of ECIP

•

entry on the 'e$site as a Supervisor approved $y the sponsoring %em$er &rganisation 

• entry onto the 'e$site as a !rainer approved $y the sponsoring %em$er &rganisation  

Please  as appropriate

"ignature:

$ame (please print)

Position in 'ember rganisation (please print)

$ame of 'ember rganisation (please print)

7/21/2019 ECIP Application

http://slidepdf.com/reader/full/ecip-application 2/2

EUROPEAN ASSOCIATION FOR  INTEGRATIVE PSYCHOTHERAPY

European Certificate of Integrative PsychotherapyApplication Form

Please note

!'o copies of this form must be completed for each individual applicant!

oth copies should be sent with confirmation of a ban* transfer of + euro, - euro or . euro (see above) to /ayConroy, egistrar, EAIP egistered ffice, 01 "toneview Place, #un 2aoghaire, Co! #ublin, IE2A$#, who will issuethe certificate! Payment may be made by PayPal to eaipdublin3gmail!com! 4ees may be transferred electronically asfollows:

$ame of an* account European Association for Integrative Psychotherapyan* address Permanent %", ld utterfield Avenue, athfarnham, #ublin 05IA$ IE.0 IP" ..67 51+1 151 55IC IP"IE1#

A certificate cannot $e issued 'ithout completed and signed application forms and until payment is received

$y !reasurer(

&hen awarded the ECIP the certificate holder will be registered with EAIP as an Integrative Psychotherapist!egistration is renewable annually at a fee of 56 euro, 6 euro if also entered on the website as a "upervisor, 76 euroif also entered on the website as a %rainer! 8ou will automatically be informed when your registration is due forrenewal! If you do not wish to renew your registration, your details will be removed from the EAIP register andwebsite!