:: Initial Applications ::

MASSAGE THERAPY APPLICATION PACKAGE REQUEST FORM

Instructions Step 1 / 4

Fee Schedule

Application Fee: $25

Demographics Step 2 / 4

First Name

Middle Name

Last Name

Address1

Address2

City

State

Zip

Telephone Number

Fax Number

E-Mail Address

Date of Birth

SSN

Preview Step 3 / 4

Affirm and Submit Step 4 / 4

E-Signature

Date

Fee

Convenience Fee

Total

Person`s Name on Card

Card Number

Card Type

Expiration Date (MM/YY)

Security Code

Billing Zip Code

2777 Zelda Road
Montgomery, AL 36106

Phone (334) 420-7233
Fax (334) 263-6115