First Name(required)

Last Name(required)

Email Address (required)

Address (required)

City (required)

Zip code(required)

State
Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

Mobile Phone No.

Day Time Telephone No.(required)

Date of Birth(required)

Please select the applicable answers:

Do you have access to a portable massage chair?(required)
Select Yes No

Do you have your own transport?(required)
Select Yes No

Are you prepared to travel?(required)
Select Yes No

Do you have valid liability insurance? (Public liability insurance required)
Select Yes No

Years of experience in chair massage(required)

Current work status

Have any claims ever been brought against you, or are any claims pending regarding your work as a therapist? If applicable, please provide details:(required)
NO claims ever been brought against me, and there are NO claims pending regarding my work as a therapist

By Submitting Application:

I confirm that all the information I have provided is correct to the best of my knowledge.(required)

I confirm I will represent the best interest of the company at all times in accordance with all company policies/procedures.(required)

I give my permission for TravelChair Massage to hold this information on file.(required)

I confirm I will abide by all applicable laws and regulations.(required)