Application for Membership

Name:_______________________________________Business Name:________________________________

Address:_____________________________________Business Address:______________________________

_________________________________________________________________________________________

Telephone No. (home):__________________________(work):______________________________________

(Fax):________________________________________(other):______________________________________

E-mail:____________________________________________________________________________________

The Following information is required for Full Member Applications

Date of Birth: _________________________________Social Security #: ______________________________

Total Hours of Training:______________________________________________________________________

Total Years of Practice: _________________________Or In Practice Since:____________________________

Certifications:______________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Affiliations: ABMP AOBTA IM A NCBTM B Other ____________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Professional Liability Insurance carrier and number:________________________________________________

Membership type:

Full Member $75.00

Legislative Support $30.00

All of the following must be submitted:

1. Application processing fee: $10.00

(Waived for Full M ember Applications with Proof of Liability Insurance,

Not required for Legislative Support Applications)

2. Annual Dues for membership type

3. Documentation of Certifications.

4. This application with required signatures.

By signing this application, I understand that all fees paid to MTMN are non-refundable and can not be prorated. I also verify that my license, certification, and/or registration pertaining to massage, bodywork or somatic therapies has never been suspended or revoked and that no disciplinary action has been taken or is pending against me. In addition, I have never been accused of, arrested for or charged with any sexual violations. I understand that my signature shall verify that I have completed the MTMN membership application accurately and honestly. I understand that any false statement made on this application or subsequent renewals shall void this application, terminate my membership and I may be subject to legal action. I understand that MTMN members are required to maintain the highest standards of professional conduct and strictly adhere to the MTMN Code of Ethics. I understand that violation of the MTMN Code of Ethics will result in immediate termination of my MTMN membership and render all benefits of membership null and void. Returned checks will be charged a $25.00 administrative fee.

SIGN HERE:______________________________________D ate:______________________

Signature (REQUIRED)

Rev 02/07/2000