RLT Registration Form

Registered Laser Therapist, RLT® Application Form

Canadian Association of Medical Spas and Aesthetic Surgeons (CAMACS).
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)
Optional
Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Cell Phone Number
Work Phone Number
Please choose one or more that describes your status

I am a Medical Laser PractitionerI am a business owner / employer / rep.I am an instructorI am an institution directorI am a studentOther
Most Recent Degree / 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:

Cancelof
Attach your resume / work history / CV

PDF, WORD, or Peg file
Cancelof
How long have you been practicing medical / cosmetic lasers on clients?
Work Experience
Please indicate what types of laser machines you have operated:
Brand name, Manufacturer, Wavelengths, Application
Upload a formal picture for your RLT certificate

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Method of Payment
Please leave the payment information blank.

Registered Laser Therapist Application Fee / Year

RLT Registration

$250.00CAD

Total

$0.00CAD

Credit Card

Date

MonthDayYear
Date
Legal name as appears on your government issued ID
Additional Comments
Signature

Clear
Should be Empty:

Registered Laser Therapist, RLT® Application Form

Credit Card