American Institute of Natural Health, Inc.

Enrollment Application
Applicant Full Name: __________________________________________________
Mailing Address: ______________________________________________________
City: _________________________ State: _________ Zip Code: _____________
Mobile Number: ______________________________________________________
Email Address: _______________________________________________________
Current Employer: ____________________________________________________
Position : ___________________________ Employer Phone: _________________
Education: __________________________ Degree/Licenses Held: ____________
Character References: (Name/Phone/Relationship)
1. _________________________________________________________________
2. _________________________________________________________________

Emergency Contact : (Name/Phone/Relationship)

____________________________________________________________________
Have you ever received a colon therapy session? Yes/No If yes, when, where and what
type of equipment was used: ___________________________________________
___________________________________________________________________

Have you ever administered a colon therapy session? Yes/No If yes, when, where and
what type of equipment was used: ______________________________________
___________________________________________________________________

Using the back of this paper, please tell us about yourself and your current plans
on becoming a Professional Colon Hydro Therapist.
08/2011
21636 N 14th Ave, #A-1 Phoenix, AZ 85027 (t) 1.800.343.4950 (f) 623.581.8724 www.shpinc.net