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1:1 Provider Application Form

Please complete the form below.

Your name:		Date:
Your occupation: How long have you been in this position? Your business name: Type of business: Your business address: Your business phone number: Other work phone numbers: Your fax number: Your e-mail address: Your alternate e-mail address: Your home address: Your home phone or cell phone: Do you prefer to receive HeartMath materials at your office or home? Who is your primary HeartMath contact? What HeartMath products or services have you used? Include all HeartMath workshops or seminars you have attended and when. What professional training have you received? Please include degrees, certifications and licenses held and dates completed. What professional organisations do you belong to? What is your professional experience working with individual clients in a 1 on 1 format? Please include dates. (e.g. I'm a wellness counselor and have been working with individual clients for 10 years. Currently I have about 10 clients a week and we meet face to face.) Why do you want to become a 1:1 Provider? How many people do you plan to teach HeartMath to within the next 12 months? Describe your targeted market and your relationship to that market. Briefly describe how you plan to market your HeartMath business. Give a brief résumé-type history of relevant profession, education and employment information in addition to that mentioned above. Please list contact information for 3 references.
Professional Name: Phone: organisation and title: Name: Phone: organisation and title:		Personal Name: Phone: organisation and title:
When you complete your 1:1 Provider training you will receive a certificate of completion. How would you like your name to appear on that certificate? e.g. Jane Smith, Ph.D. Maria Thompson Director, Training and Licensing Programs HeartMath LLC 6 Help Street/ Level 7 Chatswood 2067, NSW Australia 1:1 provider license does not allow for training groups or conducting any type of workshop or seminar. 1:1 provider license is only available to residents of North America, Australia and New Zealand. Submission of this application indicates that you have agreed to the following: I understand the submission of this application form alone does not guarantee acceptance into the 1:1 Provider Program. I agree that upon completion of my training as 1:1 Provider I will follow the terms and conditions stated in the 1:1 Agreement.

Sample License Agreement
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Application Form

For Information
Telephone: (02) 9412 2500 (Australia)
Telephone: +61 2 9412 2500 (International)
E-Mail: info@heartmath.com.au

HeartMath Australasia is an independently owned wholly Australian organisation and is one of the international licensees of HeartMath LLC USA.
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