Name: ________________________________________________________________ Address: ______________________________________________________________ _____________________________________________________________________ Telephone:__________________________(Day)________________________(Evening) E-mail: _______________________________________________________________ Date of Birth: ___________________________ SS# ___________________________

Please answer the following questions on a separate sheet of paper. 1. Have you studied therapeutic massage previously? Please explain. 2. Have you recieved professional massage or some other form of bodywork therapy? Approximately how many sessions have you received in the last two years? 3. What is your current occupation? 4. Please tell us your academic background? 5. Briefly explain how you became interested in learning massage therapy? Do you intend to work professionally?

Please provide the name, address and daytime telephone number for 3 people we may contact for a personal reference. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Class size is limited please return your application as soon as possible. You will be contacted for a personal interview with the Administrative Director. Mail the completed application along with your check or money order for the $35.00 application fee to: Therapeutic Massage Training Institute 726 East Boulevard Charlotte, NC 28203