Therapist Application

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Cell Phone *

Email *

DOB *

SSN

(or send W-9 to kelaseclients@gmail.com)

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Massage Schools & Dates Attended *

Chair Massage Training & Dates Attended *

Availability (weekdays, evenings, weekends, etc.) *

Interests/Rate of Pay (all payments go through Zelle) *

• Special Events ($55-$65 per hour plus travel fee if out of area)
• Regular Events (80% of monies collected directly from individual clients)

CAMTC # (attach copy)

CAMTC Expiration Date

Insurance Company (attach copy)

Insurance Expiration Date

In case of emergency, please notify (name & telephone number):

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By submitting this form, I hereby agree to adhere to all company policies and procedures as specified.