NAME:_________________________________ DATE ___/___/___

ADDRESS:______________________________________________

CITY ____________________________STATE_____ ZIP:___________

PHONE #:   (_________) ______________________________

BEEPER #: (_________) ______________________________

SOC. SEC. #: __________ -_______-___________

DATE OF BIRTH: _______/_______/_______ AGE: ________

STATE BOARD LICENSE # or
WORK CERTIFICATE #: _________________________________

GRADUATION DATE: _______/_______/_______

L.M.T. / BODYWORKER
INSURANCE. POLICY #: _________________________________

L.M.T. / BODYWORKER INSURANCE COMPANY

( Name of carrier): _______________________________________

PROFICIENT IN WHICH TYPES OF MASSAGE:

_______________________________________________________

_______________________________________________________

 PLEASE GIVE THREE (3) WORK REFERENCES:

1) COMPANY NAME: ___________________________________

ADDRESS: _____________________________________________

PHONE #: (_______) ________________________

JOB TITLE: _______________________________

CONTACT: ________________________________

2) COMPANY NAME: ___________________________________

ADDRESS: _____________________________________________

PHONE #: (_______) ________________________

JOB TITLE: _______________________________

CONTACT: ________________________________

3) COMPANY NAME: ___________________________________

ADDRESS: _____________________________________________

PHONE #: (_______) ________________________

JOB TITLE: _______________________________

CONTACT: ________________________________

PLEASE GIVE TWO (2) PERSONAL REFERENCES ( NO RELATIVES ):

1) NAME: _________________________________

TEL. # (_______) ___________________________

HOW LONG? ______________________________

2) NAME: _________________________________

TEL. # (_______) ___________________________

HOW LONG? ______________________________

DO YOU HAVE MASSAGE TABLE (____), CHAIR(____)

DATE YOU CAN START: _____/_____/_____

WHAT ARE YOUR SHORT & LONG TERM CAREER GOALS?:

________________________________________________________

________________________________________________________

TOTAL NUMBER OF JOBS YOU CAN HANDLE PER DAY:___________

DESCRIBE YOUR IDEAL WORKING CONDITIONS and towns you can

service:_________________________________________________________

_______________________________________________________________