Full Name:__________________________________________________

Your Name at grad. of MT school: (if diff.) __________________________

Address:________________________________________________

City:______________________________ State:____ Zip:__________

SS#:___________________ Date of Birth:_____________

Phone #:___________________ Cell or other: __________________

Provide information on the MASSAGE THERAPY SCHOOL you graduated from:

School Name:____________________________________________

Address: ________________________________________________

City:_____________________ State:____ Zip:_____________

Date of Graduation:_________________

I am applying to attend the following Recertification Program(s):

____ Basic Science - Full 10 week course - 40 hrs. $500 1 class/week: Spring or Fall

I understand that ATTENDANCE AT EVERY CLASS IS MANDATORY and that I must complete this program with PASSING GRADES in order to receive the Certificate of Completion.

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