New York State Society of
Medical Massage Therapists, Inc.
Membership Application and Renewal Form
(Please complete all applicable sections.)
First Name
Last Name
Name of Business
Mailing Address
Apt#
(Please list address where you wish to receive mail.)
City
State
Zip
Telephone Number
(i.e. 123-555-5555)
Email Address
NYS Massage License #
Expiration date of registration
(mm/dd/yy)
Membership Dues:
New members are accepted throughout the year.
Please Check One.
Professional LMT Membership
$100
Renewal
(NYS Licensed Massage Therapist)
New Member
* (NYS Licensed Massage Therapist)
Senior Membership
$50
Active
(65 years old & practicing)
Non-Active
(65 years old & not practicing)
Student Membership
$50
(Currently enrolled in massage school)
Name of School
Affiliated Membership
$100
(Other health care professionals or a Massage Therapist not practicing in NYS)
Profession
School Membership
$100
Name of School
Director
Corporate/Business Membership
$100
Minimum Enrollment of 5+ employees receives a 25% discount for each employee. Please note that each person listed below must complete their own NYSSMMT Membership Application.
Company Name:
Owner:
Employee:
1.
$75
2.
$75
3.
$75
4.
$75
5.
$75
6.
$75
7.
$75
8.
$75
*New Members Please Complete:
Date of birth
Month
1
2
3
4
5
6
7
8
9
10
11
12
Year
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
1909
1908
1907
1906
1905
1904
1903
1902
1901
1900
Massage School Attended
Graduation Date
(mm/dd/yy)
Please list two references:
Licensed Massage Therapist; massage teacher or health care professional
1. Name
2. Name
Address
Address
City, State Zip
City, State Zip
Payment Information:
Amount $
All Members:
As a member, I agree to support and abide by the Society's Bylaws.
(Optional) Malpractice/Liability Insurance:
Signature Required - Processed by mail only.
To download an application, click
here
.
1-877-NYSSMMT (697-7668) P.O. Box 442 Bellmore, NY 11710-0442
home
|
NYSSMMT
|
massage therapy
|
members
|
news/events
|
classifieds
|
links
|
contact us
|
find a therapist
© 2008 NYSSMMT. All rights reserved.