If you are an active practitioner of PI, EI, PPI or PEI and would like to be on the ICPIT-List of Active Practitioners,
please fill out the following form.

Your information will be kept in a database by the ICPIT-Secretariat and will only be given to those people in search of a Practitioner.

* denotes required

1. Your name: *

2. Your full address: *

3. Your work address: *

4. Phone number: *

5. Mobile number:

6. E-mail address: *

7. Do you have a website? What is the URL?

8. If you are an active practitioner of any of the following, please tick appropriate box/es: *

PI		EI
PPI		PEI

9. Who were your ICPIT trainers: *

10. In what year did you receive your certificate signed both by ICRI (Jack Painter) and your ICPIT trainer/s: *

11. Any other relevant qualifications:

12. What is your specialty? Do you work with special issues?