AIMT - Massage Therapy Program - Application For Admission

To apply please print a copy of this form, fill it out, and submit via fax or mail to Attention: Director of Admissions. Fax and mailing address located at the bottom of this page.

Personal Data

Name (Last, First, Middle)
Maiden name if married.	Sex Male Female
Address Line 1
Address Line 2
City, State & Zip
Mailing Address if different from above.
Home Phone	Work phone
Fax	Email

Birth Date (mm/dd/yy)	Place of Birth
Country of Citizenship	Social Security Number

Marital Status

Single	Married
Separated	Divorced
Remarried	Widowed

Ethnic Information

Non-resident Alien	American Indian
Hispanic	Alaskan Native
Black	Asian or Pacific Islander
White Non-Hispanic	Other (Specify)

Visa Status
Immigrant (List alien number)	Visa Number
Student Visa Number	Other

Emergency Contact Information

Name (Last, First)	Relationship
Address Line 1
Address Line 2
City, State & Zip
Home Phone	Work phone

Educational Background

Circle last year attended in each category.
G.E.D.	High School 1 2 3 4
College 1 2 3 4	Graduate School 1 2 3 4
Highest Degree Attained	Date Attained
List high schools and colleges attended.
School & Location	Dates Attended	Dates Graduated




Please ask the high schools and colleges you have attended to send OFFICIAL TRANSCRIPTS to the address below to the attention of the Director of Admissions.

Work History

Present Occupation

Name of Employer/Business

Military Background

If you have served in the U.S. Armed Forces, give branch of service and approximate dates of military service.

Health Background

Describe your state of health.

Miscellaneous Background

Have you ever been convicted of a serious crime (felony)? If yes, please explain.

Enrollment Information

Please answer the following questions. Use additional pages if needed to give the Administrative Committee the necessary to determine your eligibility.

Please give a brief autobiography and statement as to why you have decided on Massage therapy as a profession.

List any previous health care training or experience.

What are your long range career plans?

References

List a reference who can attest to your suitability for the profession of Massage Therapist, preferably a health care professional or a Massage Therapist. If possible, include a letter of reference with your application.

I certify that the information above is true. I understand that it will be held in confidence, and will only be used to determine the degree to which I may benefit from this training.

Applicant's Name	Today's Date
Applicant's Signature

American Institute, is a coeducational institution established to prepare its graduates to become Licensed Massage Therapist.

The Institute is committed to equal educational and employment opportunities for men and women and does not discriminate on the basis of race, color, gender, belief or national origin among its students or employees or among applicants for admission or employment.

Massage Therapy Program Application For Admission

Massage Therapy Program
Application For Admission