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Note: Required fields are indicated by a red asterisk. If you do not have an answer for a required field please write, "NA."
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| Full Name: |
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| Phone Number: |
*
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| Alternate Phone: |
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| Email Address: |
*
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| Street Address: |
*
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| City: |
*
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| State: |
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| Postal Code: |
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| Country: |
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| Birthday: |
* (00/00/0000)
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| Driver's License No: |
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| High School Name: |
*
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| Graduation / GED Date: |
* (00/00/0000)
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| Previous College: |
*
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| Have you ever been expelled or dismissed from an educational institution? |
*
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| If you answered yes to the above question please explain the situation: |
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| Current Employer: |
*
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| Address: |
*
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| Phone Number: |
*
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| Job Title: |
*
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| Employment Dates: |
to
* (00/00/0000)
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| Previous Employer: |
*
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| Address: |
*
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| Phone Number: |
*
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| Employment Dates: |
to
* (00/00/0000)
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| Reason For Leaving: |
*
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| Do you have any medical conditions, that may influence your ability to complete your massage therapy training or that may affect you in the future as a massage practitioner? |
*
These conditions may include, but are not limited to: surgeries, injuries, diseases or psychological disorders.
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| If you answered yes to the above question please explain in detail any physical limitations that you believe may influence your ability to complete your massage therapy training. |
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| Have you ever been convicted of a felony or misdemeanor other than traffic offenses? |
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Please note: This information is confidential and will not necessarily hinder you from receiving a Washington State massage license.
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| If you answered yes to the above question please explain the situation to the best of your abilty. |
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| Personal Reference 1: |
*
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| Address: |
*
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| Phone Number: |
*
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| Relationship: |
*
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| Personal Reference 2: |
*
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| Address: |
*
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| Phone Number: |
*
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| Relationship: |
*
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| Personal Reference 3: |
*
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| Address: |
*
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| Phone Number: |
*
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| Relationship: |
*
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| Program of Interest: |
*
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| Preferred Class Schedule: |
*
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| Preferred Program Start Date: |
*
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| *
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I certify that the statements I have made in this application are complete and true to the best of my knowledge. I acknowledge that it is my responsibility to be aware of all pertinent admission and application requirements. I acknowledge that failure to disclose complete and accurate information, or failure to submit all required application materials may result in the denial of admission or subsequent dismissal from the Northwest Academy for the Healing Arts.
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| Digital Signature: |
Applicant Initials:*
Date of Application:* (00/00/0000)
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| Promotional Code: |
(Optional Promotional Code):
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I understand that my application is incomplete without my digital signature below and that, in order to be considered, my complete application must be signed and submitted prior to the application deadline.
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