Contact Information:

Name:    
Birth Date:

Full Address:
 

Home Phone:         
Mobile Phone:   
Work Phone:

 E-mail address:

Drivers License #    
State:  

Dear Applicant,

Please answer the following questions regarding your interest in becoming associated with the dynamic team at Exuberant Force.  Thank you for your interest and we will get back to you as soon as possible via E-mail.

 1.  Massage school attended and number of program hours:
      

     Address: 
    

     Phone #:

     Name or Reference of Teacher or Administrative Personnel:
    

2.  Date of Graduation:

     List all certification(s) received:
    

 3.  Have you taken the national certification exam?      Yes   No
     If yes, list date passed: 

     If you have not taken it, do you plan on taking it?      Yes   No
     If yes, when: 

     Do you have professional insurance ?   Yes   No
     If yes, list agency and phone #:

 4.  Current number of paid massage hours practiced per week:

5.  Current employer and best time/day to contact (if applicable):   
     

      Address:
       
      
       Phone Number:  

6.  How many hours during the week would you be available between 9am and 5pm to provide chair massage? 

      Please give available times/days:
     

7.  Do you own a chair? Yes   No

8.  Do you have reliable transportation?  Yes   No

    If no, please explain:
   

     Do you have any moving violations in the last 12 months?  Yes  No

     If yes, please explain:
    

 9.  Do you smoke?  Yes   No

 10. Do speak another language fluently?   Yes  No
        If yes, please list:
       

Briefly describe your work goals for the next 12 months and the approximate income you would like to generate:

Briefly describe your work goals for the next 12 to 24 months and describe the approximate income you would like to generate:

List 2 other teachers or professional associates or business references.  Please do not list friends or family members.  Include the best contact numbers and time of day to reach them:  

#1 

#2

How did you hear about us?

Code of Ethics:  We strictly enforce a policy of “non-solicitation” of our massage clients outside the scope of the Company.  If selected to become an Affiliate Massage Therapist with Exuberant Force!, would you be willing to agree to comply with this policy?

Yes