Please provide the following contact information:

COUNTRY-OF-CITIZENSHIP, IF-NOT-US ?

WHO REFERRED YOU ? OTHER FRIEND FAMILY MEMBER

US-CITIZEN-?YES NO

IF NOT A CITIZEN, ARE YOU A PERMANENT RESIDENT ?YES NO

MARITAL STATUS SINGLE DIVORCED MARITAL STATUS MARRIED

HAVE YOU PREVIOUSLY ATTENDED NEW YORK INSTITUTE OF MASSAGE ?

YES NO IF SO WHEN ?

HAVE YOU BEEN IN FOR A TOUR AND INTERVIEW ? YES NO

ARE YOU INTERESTED IN : MORNING AFTERNOON EVENING CLASSES

                                         JANUARY APRIL JULY OCTOBER

WILL YOU ENTER AS ? (PLEASE PICK ALL THAT APPLY) FULL TIME PART TIME TRANSFER ORIENTAL MASSAGE(SHIATSU)

HOW DID YOU PLAN ON PAYING YOUR TUITION? PERSONAL LOAN CREDIT CARD INSTALMENTS * NYIM FINANACING * VESID JTPA TRA DWF PERSONAL FUNDS OTHER

* TO QUALIFY FOR INSTALLMENTS OF NYIM FINANCING, THE FINANCIAL ASSISTANCE PAPERWORK MUST BE ON FILE WITH YOUR APPLICATION PLEASE CALL THE SCHOOL FOR FINANCING APPLICATION.

EMPLOYMENT HISTORY

CURRENT EMPLOYERS NAME

MAILING ADDRESS

PHONE NUMBER (INCLUDE AREA CODE) SALARY

YEARS WORKED: POSITION

EMPLOYMENT DATES WITH CURRENT COMPANY:

DOES YOUR COMPANY OFFER A TUITION ASSISTANCE PROGRAM ? YES NO

PLEASE LIST TWO (2) REFERENCES EITHER PERSONAL PERSONAL OR PROFESSIONAL (NO RELATIVES PLEASE)

NAME:        NAME: 

ADDRESS:    ADDRESS:

OCCUPATION:   OCCUPATION:

PHONE NUMBER:   PHONE NUMBER:

SCHOOL BACKGROUND

NAME OF SCHOOL FROM WHICH YOU DID / WILL GRADUATE DATE OF GRADUATION

ADDRESS:

CITY: STATE: ZIP CODE:

SCHOOL PHONE NUMBER:

YOU MUST SUBMIT A COPY OF YOUR HIGH SCHOOL TRANSCRIPT OR G.E.D TO THE NEW YORK INSTITUTE OF MASSAGE. PLEASE HAVE OFFICIAL TRANSCRIPTS MAILED DIRECTLY TO OUR OFFICE FROM YOUR HIGH SCHOOL.

COLLEGE EXPERIENCE / MASSAGE SCHOOL EXPERIENCE

IF YOU HAVE ATTENDED A COLLEGE, UNIVERSITY, OF MASSAGE SCHOLL, LIST NAMES AND DATES ATTENDED. (LIST SCHOOLS WHETHER YOU EARNED CREDITS OR NOT

NAME OF COLLEGE / MASSAGE SCHOOL AND DATES OF ATTENDANCE, CITY & STATE, FROM, TO, HOURS, GRADUATION

NOTE: BEFORE ANY STUDENT MAY ADMITTED AS A TRANSFER STUDENT, OFFICIAL TRANSCRIPTS AND CATALOG OF PREVIOUS COLLEGE OF VOCATIONAL WORK MUST BE ON FILE IN ADMISSIONS OFFICE.

ARE YOU A VETERAN? YES NO IF YES, DATES OF ENLISTMENT:

DATE OF DISCHARGE: BRANCH OF SERVICE:

ARE YOU CURRENTLY TAKING AND MEDICATION? YES NO IF YES WHAT TYPE: ARE YOU UNDER A PHYSICIAN’S CARE? YES NO IF YES, WHAT FOR :

IS THERE ANYTHING YOU WOULD LIKE US TO KNOW ABOUT YOUR PHYSICAL OF MENTAL CONDITION?

DO YOU HAVE ANY DISABILITIES THAT YOU WOULD LIKE TO VOLUNTARILY DISCLOSE? IF SO, WHAT REASONABLE ACCOMMODATIONS WOULD YOU NEED TO ENSURE A HIGH QUALITY EDUCATION?

NOTE : NEW YORK INSTITUTE OF MASSAGE REQUIRES A MEDICAL RELEASE FORM STATING THAT YOU ARE ELIGIBLE FOR GIVING AND RECEIVING MASSAGE.

PLEASE READ CAREFULLY AND SIGN

HAVE YOU EVER BEEN CONVICTED OF A CRIME (FELONY OR MISDEMEANOR) OR PLEADED GUILTY TO A CRIME IN ANY STATE OF COUNTRY? YES NO IF YES, A COPY OF THE POLICE REPORT MUST BE SUBMITTED TO ADMISSION OFFICE, AND PLEASE EXPLAIN DETAILS BELOW:

IN ORDER TO COMPLY WITH FEDERAL REPORTING VETERANS BENEFITS WE NEED TO KNOW THE FOLLOWING ETHNIC BACKGROUND: AFRICAN AMERICAN /BLACK HISPANIC/LATIN ASIAN AMERICAN CAUCASIAN/WHITE INDIAN OR ALASKAN NATIVE OTHER: I CERTIFY THAT THE INFORMATION ON THIS FORM IS BOTH COMPLETE AND ACCURATE. I UNDERSTAND THAT FALSIFYING ANY PART OF THIS APPLICATION MAY RESULT IN MY BEING REFUSED ADMISSION O BEING REQUIRED TO WITHDRAW FROM THE INSTITUTE.

NOTIFY IN CASE OF EMERGENCY:    PHONE NUMBER:

SIGNATURE:   DATE