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)

EDUCATION

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)

Is your Zelle account attached to your cell number or email?Cell Phone aboveEmail Address above

CAMTC # (attach copy)

CAMTC Expiration Date

Insurance Company (attach copy)

Insurance Expiration Date

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

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