Massage Training - Massage Training Institute, Montana

Date*

Name*

First Middle Last

Date of Birth*

Mailing Address*

Mailing Address City State / Province / Region ZIP / Postal Code

Phone Number

Email Address

Social Security #*

Gender

Male
Female

Occupation

In Case Of Emergency, Please Contact:

Name*

First Last

Relationship to Student*

Address*

Street Address City ZIP / Postal Code

How Did You Hear About Our School?

Fall Class

Education

Name of High School City State / Province / Region

Date Graduated

Name Recorded on Transcript (if Different From Application)

Education

Name of University or College City State / Province / Region

Date Graduated

Name Recorded on Transcript (if Different From Application)

Degree or Certification

Personal Legal Information:

Please be aware that if you answer yes to any question below, your ability to obtain a License to practice massage in the State of Montana or elsewhere may be impeded or prohibited.

Have you ever been convicted of, or entered a plea of guilty, or no contest to, a crime in any jurisdiction other than a minor traffic offense? (This includes misdemeanors, felonies, and withheld adjudications. Driving under the influence or driving while impaired is NOT a minor traffic offense for purposes of this question.)

YES
NO

In the last 5 years, have you been enrolled in, required to enter into, or participated in any drug or alcohol recovery program or impaired practitioner program?