APPLICATION FOR STUDENT MEMBERSHIP

Surname

First Name

Initial

Street Address

City

Province

Postal Code

Telephone

Cellphone

Date of Birth

Education

Name of massage therapy school you are attending

Expected Graduation Date (YYYY/MM/DD)

Declaration

You are required to answer the following questions:

I am at least nineteen years of age.

YES NO

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

YES NO

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

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

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 applications, I have made false or misleading representation either because of what I have stated or because of what I have not stated.