AMTA Massage Information Center Request Form

*required

Check one that applies*

• Member
• Non-Member Massage Therapist
• Consumer
• Media

First Name

Last Name

Member ID

Address

Street name and number

Suite, building, etc.

City

State

ZIP code

Email

Ex: name@example.com

Phone

Ex: 555-555-5555

Fax

Briefly describe what type of information you are looking for:

Note: Please make sure this form is COMPLETELY filled out and has the information you want published before hitting submit. Once you hit submit there is no opportunity for you to go back and correct typos or wrong phone numbers, etc. Do not hit your back button on your browser and re-submit corrected information.