Professional Contractor Information

    Contractor First & Last Name:*

    Massage License #:

    Upload Professional license if scanned copy

    Date Issued:*

    Driver License, Personal Identification Number:

    Upload Driver license if scanned copy

    Massage Insurance Name:*

    Policy #: Esthetician* YesNo

    Esthetician License Number:

    Additional Holistic Certifications:

    * * * * * Days/Times Unavailable For Work, If Available leave Blank Monday Hours

    TuesdayHours

    WednesdayHours

    Thursday Hours

    FridayHours

    Saturday Hours

    SundayHours

    PROFESSIONALS CONTACT:

    Phone #:*

    Full Address

    Social #:*

    Emergency Contact Name & Number:*

    Professional Massage License Conduct Discrepancies/Deviations:*

    Select* YesNo

    If Yes Please Detail:*

    Professional Esthetician License Conduct Discrepancies/Deviations:*

    Select* YesNo

    If Yes Please Explain:*

    Select* YesNo

    If Yes Please Detail:*

    DIRECT DEPOSIT INFORMATION*

    Bank Name:*

    Bank Type* BusinessPersonal

    Business/Practice Name:

    Account #* Routing#* Account Type*

    Email:*

    Preferred Phone Number For Accepting Appointments #:*

    Date:

    I certify that the information submitted in this application is true and correct to the best of my knowledge. I further understand that any false statements may result in non-acceptance or revocation of the Eminence Massage LLC Contract.

    Initials*: