PROVISIONAL MEMBER REGISTRATION FORM

Please indicate how the fees will be paid:

CPR/First Aid Certification Criminal Record Check Proof of Graduation or Proof of Membership in a College of Massage Therapy, if applicable OSCE & MCQ Results (confirmation letters) Proof of insurance coverage (copy of policy), if applicable Two pieces of government-issued identification (one piece must be photo identification)

Membership Fees

Payment options: Cheque, Money Order, Credit Card (contact the ANBMT to pay using a CC anbmt@anbmt.ca). You can e-transfer your member fees directly to us (membership fee to the ANBMT & insurance payment to BFL Canada) Just use the ANBMT's email address anbmt@anbmt.ca. Make a note that the payment is for you (include your name and address).

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 BFL CANADA. If you currently have Liability Insurance with a provider other than BFL Canada please fill out the following form below and include a copy of current insurance policy:

I hereby certify that I have $

liability insurance with

which is valid until

Please fill out the information below and send the combined payment including membership renewal and BFL Canada Insurance to the ANBMT.

Total Payment (See Link for the Table below) Membership Fees

1. Have you ever been convicted or charged with, and not found guilty or acquitted of a criminal offence?

YES NO

2. Has there ever been a finding of professional misconduct, incompetence or incapacitation or any like finding in relation to the profession or another health profession?

YES NO

3. Is there a current proceeding against you involving an allegation of professional misconduct, incompetence, or incapacitation or any like finding in relation to your practice of massage therapy or another health profession?

YES NO

4. After becoming a member in a College and/or an Association of Massage Therapy, has there ever been a time when you were not a member in good standing in this College and/or Association?

YES NO

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.