CMMOTA Annual Declaration

CMMOTA Annual Declaration

This form must be filled out and completed on an annual basis in order for Membership Renewal to be approved.
Member Name*

First NameLast Name
Email Address*
example@example.com
Member Number
eg. 0123
Mobile 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

CityState / Province

Postal / Zip Code

I hereby declare the following:
Statement 1 – I have entered into a peace bond agreement or have been charged with, pleaded guilty to, or been found guilty of any offence inside or outside of Canada that is inconsistent with the proper professional behaviour of a massage therapist, including a conviction under any of the following for which no pardon has been granted: the Criminal Code (CANADA), or the Controlled Drugs and Substances Act (CANADA).*
If yes, please provide an explanation:*
Statement 2 – I have been the subject of an investigation or disciplinary process in a jurisdiction that regulates massage therapists or manual osteopathic therapists, or by another association which represents these professions.*
If yes, please provide an explanation:*
Statement 3 – I have been found guilty of a disciplinary finding in a jurisdiction that regulates massage therapists or manual osteopathic therapists, or by another association which represents these professions.*
If yes, please provide an explanation:*
Statement 4 – I have had a licensing sanction imposed by a jurisdiction that regulates massage therapists.*
If yes, please provide an explanation:*
Statement 5 – I have had my membership revoked by another association.*
If yes, please provide an explanation:*
Statement 6 – I am currently a member of another professional association or regulatory college. (E.g. Nurses Association, Manual Osteopathic Association, Massage Association, College of Massage Therapy of Ontario, etc.)*
If yes, please provide an explanation:*
Statement 7 – I have read and understand the membership requirements for my class of membership.*
If no, please provide an explanation:*

I, First Name Last Name , declare my answers to these statements to be true, and understand that a false declaration would be a fraudulent act, and may result in my removal from the association, and subsequent action that may be taken against me either through civil or legal means.
Signature of Member (Typed Name is Considered Digital Signature)

First NameLast Name
Signed this day of Date at City Province
Should be Empty:

CMMOTA Annual Declaration

I hereby declare the following: