PROVISIONAL MEMBER REGISTRATION FORM

PROVISIONAL MEMBER REGISTRATION FORM

*Place you reside for the majority of the time

Home Address

Business/Employment Address

Please Provide a Copy of the Following

Membership Fees

See table below. Payment options: Cheque, Money Order, or PayPal (only credit card option) You can NOW e-transfer your member fees directly to us (membership & insurance–all one payment)! Just use the ANBMT's email address anbmt@anbmt.ca for the transfer. Make a note that the payment is for you (include your name and address). Or send a cheque, money order, or pay online using PayPal.

Insurance Registration

You can get additional information about these insurance policies by visiting the ANBMT website at http://anbmt.ca/index.php/forms/insurance-registration-renewal and by clicking on “Lackner McLennan”. If you currently have Liability Insurance with a provider other than Lackner McLennan please fill out the following and include a copy of current insurance policy:

Please fill out the information below and send the combined payment including membership renewal and Lackner McLennan insurance to the ANBMT.

Total Payment (Choose the appropriate amounts in the Table below)

Month of Initial Membership ANBMT Membership Fees ($) LACKNER MCLENNAN Liability and Malpractice Insurance Fees ($) Insurance Program Administration Fee ($) ANBMT Membership Fees ($) with LACKNER MCLENNAN Liability and Malpractice Insurance Fees ($)

January

$146.25

$81.00

$5.00

$232.25

February

$130.00

$72.00

$5.00

$207.00

March

$113.75

$63.00

$5.00

$181.75

April

$97.50

$54.00

$5.00

$156.50

May

$81.25

$45.00

$5.00

$131.25

June

$65.00

$36.00

$5.00

$106.00

July

$48.75

$27.00

$5.00

$80.75

August

$32.50

$25.00

$5.00

$62.50

September

$16.25

$25.00

$5.00

$46.25

October*

$195.00*

$108.00*

$5.00*

$308.00*

November

$178.75

$99.00

$5.00

$282.75

December

$162.50

$90.00

$5.00

$257.50

Total Payments:

TypeAmount ($)Total Payment ($)
ANBMT Provisional Member See Table  
LM Liability See Table  
Total Payment ($)    

IMPORTANT NOTES REGARDING PAYMENT:

  • Please make ALL fees payable to ANBMT, including Lackner McLennan Ltd. Professional Liability insurance fees. This is a combined payment.
  • There will be a $20.00 administration fee charged for cheques that are returned to the ANBMT “NSF” (non-sufficient funds).
  • Payment within Canada may be done using a personal cheque. If your payment comes from outside of Canada (e.g. United States), please make the payment using a money order in CAD$ (Canadian banks do not accept foreign personal cheques).
  • You can NOW e-transfer your member fees directly to us (membership & insurance–all one payment)! Just use the ANBMT's email address anbmt@anbmt.ca for the transfer.
  • If you would like to pay your fees using PayPal (only credit card option), please go to the ANBMT website at http://anbmt.ca/index.php/members/online-payment and you will find a fees table outlining the different fee options. Please click on Buy Now in the column on the right-hand side of the “Fees Table” in the appropriate row. Please also forward your membership renewal form indicating that you have paid using PayPal.

Declaration

I hereby authorize the Association of New Brunswick Massage Therapists to make such inquiries about me as it considers appropriate in connection with this application. I understand that I am deemed not to have satisfied the standards and qualifications for a certificate of registration if, in connection with this application or past application, I have made false or misleading representation, either because of what was I stated or left un-stated.