Print This Page
Application for Online (Panama-based web server) Oriental & Shiatsu
Massage Therapy Training & Certification Course
Please complete this massage training application by neat printing and legible black ink, along with your
signature, scan your completed application, and then email the scanned application as an email attachment.
to the Course Administrator whose email address is manager@asian-oriental-massage.com

Full name:_________________________________________________________________________________________

Mailing address:____________________________________________________________________________________

City:________________________________ State/Province: ______________________  Postal Code: _______________

Country:_________________________________  Daytime phone: (___________ )_______________________________ 

Email address:_____________________________________________________________________________________

Designation [s] I desire [upon successful completion of each certification designation training program]---:

       ____ Certified Oriental Massage Therapist---The low tuition and certification fee is only US$75.00.

       ____ Certified Shiatsu Massage Therapist---The low tuition and certification fee is only US$75.00.

     ____ BOTH Certified Oriental Massage Therapist and Certified Shiatsu Massage Therapist---If you want to be trained and certified as BOTH a Certified Oriental Massage Therapist and a Certified Shiatsu Massage Therapist, the low tuition and certification fee for the two professional designations is a combination tuition  total of only US$125.00.
    
       All payments are in US$, or the equivalent value of another widely-accepted currency.

If you have completed ANY post-high school college, trade, or technical education programs of any kind, please provide the details including school name, school location, year of graduation or completion of course, subjects studied, and any other helpful info. Attach extra sheets of paper if needed.

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Please describe in detail all or your business/work/career experiences that you believe would be helpful to your successful career as a Certified Oriental Massage Therapist and/or Certified Shiatsu Massage Therapist.  [please include details such as skills learned]. Attach extra sheets of paper if needed.

_____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

I certify that the above information is totally true and complete.  I understand and agree that the Course's online massage training is provided by the Course web server in the nation of Panama, and that the Course has not been approved and registered as an educational curriculum by any governmental agency in my nation of residence.

___________________________________________________                                     ____________________

                                              My Signature                                                                                                          Date


         ___________________________________
                               My Name Printed