We are always looking for dependable and professional service providers. Please complete the application below and we will be in contact with you.

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Personal Information

First Name*

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Last Name*

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Company Name (Optional)

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Email*

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Cell Phone*

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Secondary Phone*

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Address*

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City*

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State*

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Zip Code*

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Insurance & Licensing (if applicable)

Liability Insurance Provider

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Liability Insurance Policy #

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Liability Insurance Exp Date

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Professional License

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License Number

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License Expiration Date

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Professional References

Reference Name

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Phone Number

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Relationship

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Reference Name

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Phone Number

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Relationship

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Miscellaneous

How many hours of professional training have you had?

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Have you had specific training in Chair Massage?

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How many years have you been practicing?

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Can you provide all necessary equipment and supplies?

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Do you have your own practice and/or do you provide services for other companies or individuals?

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Please state all certifications & dates obtained; special techniques

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Why did you become a Massage Therapist?

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List any accomplishments, honors and awards you have received.

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Additional Comments

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Verification*

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