First Name

Last Name

Preferred Name

Please indicate which massage certifications you hold by entering your certificate numbers.

CAMTC Number

NCBTMB Number

Other Massage Certification (Indicate Type and Number)

Please provide your following information for payments to be mailed to you by bank check. We will collect bank information for Direct Deposit in a separate process.

Name of Payee (Your Name)

Street Address 1

Street Address 2

City

State

Zip

Phone Number

What smartphone do you use? (e.g. Apple iPhone 5s or Samsung Galaxy 3)

On a desktop PC/Mac, what Calendar app/software do you use? (e.g. Google Calendar, Yahoo Calendar, Microsoft Outlook, etc.)

Email Address

Please indicate which massage modalities are able to perform.

Swedish
Relaxation
Deep Tissue
Acupressure
Shiatsu
Thai
Sports
Reflexology
Aromatherapy
CranioSacral Therapy
Sensual Paradise Massage
Couples Massage
Home Visits
Hotel Room Visits
On Site Events
Chair Massage
Body Scrubs
Body Wraps
Facials
First-time Clients
Repeat Clients
Other - please indicate in next line

Please indicate any other massage modalities and skills you are able to provide:

Please indicate which equipment you have and can take to a client site:

Massage Table
Massage Chair
Shiatsu Mat

Are there any other massage or business skills you wish to indicate to add to your profile?

Finally, please share something interesting and unique about yourself. :)

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