LMT (Independent Contractor) Application

In lieu of this form, resumes and/or paper applications are being accepted in office at The Back Alley Chiropractic, 2060 E Tangerine Rd #182. Informal on-site interviews are available Mon-Thu 7am to 2pm. A 30-minute practical interview will be scheduled following informal interview.

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Full Name *

First

Last

Phone Number *

Email *

Street Address

City

State

Zip Code

Massage School Name *

Graduation Date *

Arizona License # *

Have you ever received a disciplinary action? *

• Yes
• No

Other Professional Certifications

Relevant Training or Courses

Areas of Expertise *

• Aromatherapy
• Cranialsacral
• Cupping Therapy
• Deep Tissue
• Hot Stone
• Kiniseo Taping
• Lymphatic Draining
• Myofascial Release
• Neuromuscular
• Oncology Massage
• Personal Injury
• Pre/Post-natal
• Reflexology
• Relaxation
• Sports Injury
• Swedish
• Trigger Point

Current Employment *

Job Title *

Start Date *

End Date *

Reason for leaving *

Job Responsibilities *

Prior Employment *

Job Title *

Start Date *

End Date *

Reason for leaving *

Job Responsibilities *

Additional Relevant Employment History

Availbility to Start *

Preferred Weekly Schedule *

Preferred Daily Hours *

Professional Liability Insurance *

Liability Limits *

Policy Term Date *

Reference 1 *

First

Last

Relationship *

Contact Info *

Reference 2 *

First

Last

Relationship *

Contact Info *

Reference 3 *

First

Last

Relationship *

Contact Info *

Reference work Weekly

Are you legally authorized to work in the United States? *

• Yes
• No

Have you ever been convicted of a felony? *

• Yes
• No

Applicant's Signature *

By entering my full name, I certify that my answers are true and complete to the best of my knowledge. If this application leads to a contracted agreement, I understand that false or misleading information in my application or interview may result in my release.

Signature Date *

Submit