Contractor Application First Name * Last Name * Street Address City State Zip Code Nearest Metro Area - None -ALBUQUERQUEATLANTAAUSTINBALTIMOREBOSTONCHARLOTTECHICAGOCINCINATTICLEVELANDCOLUMBUSDALLAS - FT WORTHDENVERDETROITEL PASOFRESNOHOUSTONHONOLULUINDIANAPOLISJACKSONVILLEKANSAS CITYLAS VEGASLONG BEACHLOS ANGELESMEMPHISMIAMIMILWAUKEEMINNEAPOLISNASHVILLENEW YORKNEW ORLEANSOAKLANDOKLAHOMA CITYOMAHAORLANDOPHILADELPHIAPHOENIXPITTSBURGHPORTLANDSACRAMENTOSAN ANTONIOSAN DIEGOSAN FRANCISCOSAN JOSESEATTLEST LOUISTUCSONWASHINGTON DC Cell Phone Secondary Phone E-Mail Address * Company Name (optional) What type of service provider are you? - None -Massage TherapistAestheticianNail TechnicianAromatherapistYoga InstructorOther Insurance & Licensing (if applicable) Liability Insurance Provider Professional License Liability Insurance Policy # License Number Liability Insurance Exp Date License Exp. Date Professional References Reference #1 Reference #2 Phone Number Phone Number Relationship Relationship miscellaneous How many total hours of professional training have you had? Have you had specific training in Chair Massage? - None -Yes, in massage school.Yes, as an extra course.No. How many years have you been practicing? Can you provide all the necessary equipment & supplies? - None -YesNo Do you have your own practice and/or do you provide services for other companies or individuals? - None -YesNo Additional Comments
