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
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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