Member Reinstatement Application
Personal Information
Full Name
*
First Name
Last Name
Personal Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Alt. Phone Number
Please enter a valid phone number.
Mailing Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Previous CMMOTA Membership Number:
Use 0000 if you do not know.
Class of Membership to Be Reinstated:
*
Full/Registered Massage Therapist/Spa Therapist
Student Massage Therapist
Associate Massage Therapist
Inactive Massage/Spa Therapist/MOT
Combined Member (RMT/MOT)
Manual Osteopathic Therapist
Vulnerable Sector Check or Receipt (if applicable)
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Vulnerable Sector Checks must have been obtained in the last 90 days.
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Standard/Intermediate First Aid Level C CPR or Confirmation of Course Date (if applicable)
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Professional Information
The following information will be posted on the website under "Find a Therapist."
Business Name
Business Website
eg., www.cmmota.com
Business Email
example@example.com
Business Phone Number
Please enter a valid phone number.
Business Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Would you like us to add this to your profile?
Please Select
Yes
No
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Have you ever been a member of a professional association or massage therapy college?
*
Yes
No
If yes, please name association(s) / college(s), your membership number, and when you had a membership:
*
Please provide a letter of good standing, if you have one:
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Has a professional association or college ever denied you admittance into their organization?
*
Yes
No
If yes, please state the organization and their reasoning:
*
Has your membership ever been cancelled with a professional association or college?
*
Yes
No
If yes, please state the organization and their reason for cancellation:
*
Did you ever have a complaint filed against you while being a member of a professional association or college?
*
Yes
No
If yes, please state the organization involved and describe the details of the complaint:
*
Are you a Canadian Citizen?
*
Yes
No
If no, please provide proof that you are eligible to work in Canada:
*
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Is English your First or Primary Language? If no, proof will need to be submitted to show that you can meet our Language Fluency policy
*
Yes
No
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Personal Information Protection Act (PIPA)
In order to provide, maintain, and enhance member services, the Canadian Massage & Manual Osteopathic Therapists Association (CMMOTA) collects personal and business-related information through the Membership Application process. By signing this form, you consent to CMMOTA’s collection, use, and disclosure of your personal and business information as outlined below.CMMOTA may use and publish your information — excluding your date of birth and any personal contact details that differ from your business contact information — for purposes including:• promoting CMMOTA membership and member services;• conducting statistical and membership analyses;• communicating with third parties in connection with CMMOTA’s business operations;• enforcing and administering CMMOTA’s Bylaws and Policies (as amended from time to time); and• any other lawful purpose that supports the objectives and business of CMMOTA and its membership.This consent remains valid for the duration of your membership unless revoked in writing. Written notice of withdrawal of consent must be delivered to the CMMOTA Head Office.By signing below, you also consent to the publication of your business contact information and treatment modalities in various formats as required from time to time, including in the Find a Therapist section of the CMMOTA website.
*
First Name
Last Name
I, the undersigned, do hereby solemnly affirm that the information provided and the statements contained in this application and any supporting documents are true, complete, and correct. I understand that any misrepresentation, omission, or falsification of information may result in the denial, suspension, or revocation of membership with the Canadian Massage & Manual Osteopathic Therapists Association (CMMOTA).
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Requested Effective Date
*
-
Month
-
Day
Year
*Effective Dates cannot be before the submission of your application*
How did you hear about CMMOTA?
Remember to list a name if someone referred you!
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