Professional Membership Application

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Insurance Underwriter: Lloyds of London

I am hereby applying for NEW membership in the Tennessee Massage Therapy Association.
I am applying for renewal of membership in the Tennessee Massage Therapy Association.
NOTE: If renewing, you must enter your Member Number here: (If you do not know or have forgotten your Member Number, you can Click HERE to retrieve it.)
For problems retrieving your member number please email us.
Name (As you want it to appear on your certificate):
*     * First Name:* Last Name:
* Address:
* City:* State:
* Zip:* E-mail:
Home Phone:* Business Phone:
Cell Phone:
Business Name for "Locate a Massage Therapist" listing: :
Business Address:Business City:
Business State:Business Zip:
Would you be willing to receive your newsletter via e-mail? Yes   No

State Massage License Number:
Do you hold any other state massage licenses or licenses from another profession? If yes, please list:
*What is your occupation?

Membership Options

Insurance includes professional (malpractice) liability, general (premises or 'slip & fall') liability, and product liability coverage. U.S. residents only.

New Member Professional Membership: (Without Insurance)$70.00
New Professional Membership: (With Insurance)$194.00
New Professional Membership: (With Insurance for ONE ADDTIONAL INSURED)$204.00
New Professional Membership: (With Insurance for TWO ADDTIONAL INSUREDS)$214.00
Additional Insured ONLY (Select this option if your membership is current and you just need to add an additional insured)$10.00
Enter information below for additional insureds (if any)
Additional insured #1 name:    address:
Additional insured #2 name:    address:
Additional insured #3 name:    address:
Student:(w/o insurance - Good until graduation, then apply as a new professional member)FREE
Student: Membership Plus Student Insurance - (Good for 1 year) $30.00
Friends of TMTA: (Retired Professionals/Schools)$25.00

If you currently own a Professional Liability Policy:
* With whom:
* What is the expiration date of your current policy?
* What is your date of birth? (mm/dd/yyyy)

If applying as a student:
* Name and complete address of school:
*Student: Expected Date of Training Completion: *Expected Date of Application for TN License:

Agreement

Agreement FOR PROFESSIONAL AND STUDENT MEMBERS ONLY: Please understand that TMTA is a service organization promoting massage therapy in Tennessee. Joining is a declaration of your interest in working to promote the profession and unity among massage therapists. Please be prepared to serve in some capacity to achieve these goals. Your personal involvement is a requirement for membership. I attest to the best of my ability that all of the above information is true. Further, I understand that if any of this information is discovered to be false, my application will be rejected. Also, I have read the TMTA Code of Ethics and Membership Oath and agree to abide by their guidelines.
* I have read the TMTA Code of Ethics and Membership Oath and agree to abide by their guidelines. Membership Oath.
 
You will be notified of the membership committee's decision within 30 days of receipt of completed membership application.

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