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First Name	Middle	Last Name

Street Address

City	State	Zip Code

Home Phone Area Code/Phone Work Phone Area Code/Phone Cell Phone Area Code/Phone

Email Address

Place of Birth:	Date of Birth (mm/dd/yy):

Where and when did you complete High School?

Street, City, State, and Zip Code

Phone Number

If applicant’s high school records were maintained under a name different than that listed in item #1, state name used:

To be completed if applicant attended college or received other training.

College Attended	From:	To:	Degree Attained

References: List two references other than family members:

Name	Address	Phone Number

Present occupation and employer

Job Experience: please indicate employment dates, job title, address, supervisor and phone numbers of your five most recent work experiences:

List any experience in a health-related field (not required for enrollment):

Do you have any physical or mental disabilities which may impair your ability to participate fully in all aspects of the CIMT program requirements?   No Yes If yes, please explain:
Have you ever been convicted of a Felony?   No Yes If yes, please explain:
Do you now have, or have you had in the past two years any contagious diseases?   No Yes If yes, please explain (a physical exam may be required by a licensed MD):
How did you hear about our school?   Advertisement Magazine Article Newspaper Word of Mouth Massage Therapist Friend Yellow Pages Brochure Family Surfing the Net Other

Please explaining your motivation for training in massage therapy and your philosophy of health care.

Please have your high school or latest college transcripts sent to our office: CIMT, 1490 W. Fillmore, Colorado Springs, CO 80904
Other considerations or comments you wish us to know about:

Have you ever been expelled or denied acceptance to a massage therapy or bodywork school?    No Yes

In case of emergency please contact:

Name	Relationship	Phone Number

Address

City	State	Zip Code

For security purposes, please enter into the box below the characters exactly as they are on the background (case-sensitive).