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Application for PA LicenseDrBrain2017-07-18T19:08:58-04:00

APPLICATION FOR PA LICENSE

PSMB follows the highest quality guidelines

PA License Application

Fill out form to complete application

Step 1 of 5 - Personal Information

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Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
SS# Number*
Email*
DOB*
MM slash DD slash YYYY
Country of Citizenship*
Class Times Preferred?*
- AM
- PM
Current Employment*

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Emergency Contact Name & Phone*
First Last
Relationship*
- Spouse
- Parent
- Child
- Friend
- Colleague
Email
Phone

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Massage School Attended*
- Yes
- No
If Yes, what school?
Start Date*
MM slash DD slash YYYY
End Date*
MM slash DD slash YYYY
Do you have any documentation from the PA Massage Therapy Board?*
- Yes
- No
If you have documentation, upload here:
Drop files here or

Max. file size: 100 MB.
Do you have a License to Practice Massage in other states?*
- Yes
- No
If yes, what states?
- Alabama
- Alaska
- Arizona
- Arkansas
- California
- Colorado
- Connecticut
- Delaware
- District of Columbia
- Florida
- Georgia
- Hawaii
- Idaho
- Illinois
- Indiana
- Iowa
- Kansas
- Kentucky
- Louisiana
- Maine
- Maryland
- Massachusetts
- Michigan
- Minnesota
- Mississippi
- Missouri
- Montana
- Nebraska
- Nevada
- New Hampshire
- New Jersey
- New Mexico
- New York
- North Carolina
- North Dakota
- Ohio
- Oklahoma
- Oregon
- Pennsylvania
- Rhode Island
- South Carolina
- South Dakota
- Tennessee
- Texas
- Utah
- Vermont
- Virginia
- Washington
- West Virginia
- Wisconsin
- Wyoming
- Armed Forces Americas
- Armed Forces Europe
- Armed Forces Pacific
Are you certified in any other bodywork modality?*
- Yes
- No
Please list all other modalities

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Have you ever been convicted of a crime?*
- Yes
- No
Please describe below*
Why do you want to complete your massage therapy training/education?*
How did you hear about us?*
- Spouse
- Friend
- Family Member
- Google or other search engine
- Advertisement
- Article

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Upon completing this application, I fully understand and attest that all questions have been answered truthfully and accurately.
- I have read and agree to these terms
There is a $75.00 Non Refundable Application Fee. Do you agree to these terms?**
- Yes
- No
Application Fee*
Price:
Phone
This field is for validation purposes and should be left unchanged.

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INFORMATION:

T:

E:

info@phillyschoolofmassage.com

A:

263 N. Lawrence Street
Philadelphia,PA 19106

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