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
Year
  		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

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