APPLICATION

Please print clearly:

Name __________________________________________________________________

Address_________________________________________________________________

________________________________________________________________________
City |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||| State ||||||||||||||||||||||||||||| Zip

Home Phone __________________________ Work Phone______________________

Email ___________________________________________

Massage Education:

School Attended__________________________________________________________

_________________________________________________________________________
Address
_________________________________________________________________________
City ||||||||||||||||||||||||||||||||||||||||||||||||||||State|||||||||||||||||||||||||||||||| Zip |||||||||||||||||||||||||||||||||||| Phone

Year Graduated _____________________________ Are you licensed Y______ N_____

Are you certified by N.C.B.T.M.B.? Y_________ N________ Year__________

Florida Licensees Only: License No. ____________________________________

DISCLAIMER: I acknowledge and accept that this home study program is not a
hands-on instruction course and does not grant me professional certification
as a prenatal massage therapy specialist. I agree not to represent myself as
a prenatal massage therapy specialist or expert and release Elaine
Stillerman, LMT and MotherMassage (R), her agents, representatives and
publisher of any claims that may be made against me.

________________________________________ ________________________________
Signature Date

Enclose a check or money order for $130.45 made out to Elaine Stillerman.
Mail to Elaine Stillerman, LMT P O Box 150337 Brooklyn, NY 11215-0337