Application for International Affiliate
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Online Application Form

Application for Assessment for inclusion on the Institute of Trichologists register of International Affiliate Members

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1. Personal Details

Personal Details Title & Name:
Profession:
Address 1:
Address 2:
City/Town:
ZIP/Post Code:
Country:
Phone Number:
Email address:
Website (if applicable):

2. Training
Have you trained as a Trichologist or any other related profession?
(E.g. Research into hair and scalp disorders or Dermatology or other).
If you are a medical professional or have a scientific qualification, please ignore the next 2 questions below. Please then move straight to section 4 and forward to us your Curriculum Vitae (CV).

Training Have you trained as a Trichologist or any other related profession? (E.g. Research into hair and scalp disorders or Dermatology or other). If you are a medical professional or have a scientific qualification, please ignore the next 2 questions below. Please then move straight to section 4 and forward to us your Curriculum Vitae (CV). Title of Course
Length of Course
Year of Qualification
Training Provider

3. Trichology Experience

Trichology Experience How long have you been a Trichologist or related profession?
Please state the experience that you have in Trichology and/or Associated fields which you consider that you are qualified to act as a Trichologist.
Name any other professional body that of which you are a Member

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4. Fitness to Practice

	Yes	No
Are you aware of any matters which might call into question whether you are a fit and proper person to provide professional services as a Trichologist?	*Fitness to Practice Are you aware of any matters which might call into question whether you are a fit and proper person to provide professional services as a Trichologist? Yes	Are you aware of any matters which might call into question whether you are a fit and proper person to provide professional services as a Trichologist? No
Are you aware of any matters which might call into question whether you are a fit and proper person to be associated with The Institute of Trichologists as an International Affiliate working in associated fields?	Are you aware of any matters which might call into question whether you are a fit and proper person to be associated with The Institute of Trichologists as an International Affiliate working in associated fields? Yes	Are you aware of any matters which might call into question whether you are a fit and proper person to be associated with The Institute of Trichologists as an International Affiliate working in associated fields? No
Are you currently or have you in the past 10 years, been subject to any Disciplinary or Regulatory enquires investigation or proceedings before any professional, trade or membership body or organisation?	Are you currently or have you in the past 10 years, been subject to any Disciplinary or Regulatory enquires investigation or proceedings before any professional, trade or membership body or organisation? Yes	Are you currently or have you in the past 10 years, been subject to any Disciplinary or Regulatory enquires investigation or proceedings before any professional, trade or membership body or organisation? No

5. Other information
If you have been unable to provide all the information under the headings, or if you wish to provide any other information that you consider relevant and helpful to The institute, please included it here.

Other information If you have been unable to provide all the information under the headings, or if you wish to provide any other information that you consider relevant and helpful to The institute, please included it here.

Payment
The fee for the assessment and to obtain the questionnaire is £425
This payment covers marking of the questionnaire and response from The Institute.
The link to the online questionnaire will be sent to you electronically as soon as payment has been received.
Payment is by Credit/Debit card only. A link to the secured payment options will be emailed to you upon approval of your application.

Application for International AffiliateExit this survey

Online Application Form

*1. Personal Details

3. Trichology Experience

*4. Fitness to Practice

5. Other informationIf you have been unable to provide all the information under the headings, or if you wish to provide any other information that you consider relevant and helpful to The institute, please included it here.

Application for International Affiliate
Exit this survey

*
1. Personal Details

*
4. Fitness to Practice

5. Other information
If you have been unable to provide all the information under the headings, or if you wish to provide any other information that you consider relevant and helpful to The institute, please included it here.