RLT Registration Form

Registered Laser Therapist, RLT® Application Form

Canadian Association of Medical Spas and Aesthetic Surgeons (CAMACS). 103-2228 McAllister Avenue, Port Coquitlam, British Columbia, Canada V3C 2A5 (Copyright 2019-2020. All rights reserved)
PRIVACY POLICY:
We value your privacy. We are committed to protecting your personal privacy. We will not give out your name, address, email address, credit card information or personal information ordered. This information is collected primarily to ensure that we are able to fulfill your requirements and to deliver you a truly personalized service.
Purpose of Application
Title
Medical Professional License Number if Applicable
Optional
Name

First Name Middle Name Last Name
Birth Date

Month Day Year
Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail
Cell Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Please choose one or more that describes your status

I am a Laser Practitioner I am a business owner / employer I am an instructor I am a laser company representative I am a student
Previous Education / Diploma / Certificate
Have you taken a laser course leading to a certificate or diploma?
If yes, attach a copy of your certificate or diploma here:

Browse Files

Cancel of
Attache your resume / work history

Browse Files
PDF, WORD, or Peg file Cancel of
How long have you been practicing laser on clients?
Work Experience
Please indicate what types of laser machines you have operated:
Brand name, Manufacturer, Wavelengths, Application
Please attach an ID format picture here then click on opload botton
Method of Payment
Please leave the payment information blank.
Credit Card information
Name on Credit Card
Credit Card Number
Expiry date
Three digit Security Code on Back
Date

Month Day Year
Date
Legal name as appears on your government issued ID
Additional Comments
Signature

Clear
Should be Empty:

Registered Laser Therapist, RLT® Application Form