COMTA Commission Candidate Data 2013

							                                                       Commissioner Candidate Data 2013

Thank you for your interest in being a nominee for the Commission. Below are some additional areas of
 information that we are asking you to complete and submit along with your letter of interest and your
                resume or CV. Please complete the form and sign prior to submission.



Candidate’s Name: (Please Print )
Position on Commission for which you are submitting your nomination:
    Esthetics/Skin Care Educator in COMTA                   Esthetics/Skin Care Practitioner
    accredited school or program
Highest Level of General Education: (Check all that apply)
    Less than Bachelors             Bachelors Degree          Masters Degree          Ph.D
    M.D.                            Other:
       Name and address of institution granting most advanced degree:
       Name:
       Address:
       City/State/Zip:

Number of Years of as a Post-Secondary Educator:
Areas of Expertise within Education:


Massage Therapy/Bodywork Education:
    Graduate of Non-COMTA Program                  Graduate of COMTA Program                Self-taught
    Extensive Continuing Education                 Other:
      Name of school or training program:
       Name:

       Address:

       City/State/Zip:


Involvement in Field of Massage Therapy and Bodywork: (Check all that apply)
   Employee of Non-COMTA School                   Employee of COMTA School
    Member of Professional Association (specify)              Employer Massage/Bodyworkers
    Presenter of Continuing Education Workshops               Consultant (describe)
Details:




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                                                   Commissioner Candidate Data 2013

Nationally Certified in Massage Therapy and Bodywork?            Yes        No            N/A

Number of Years of Practice in Massage Therapy/Bodywork:

Number of Years of Teaching in Massage Therapy/Bodywork:

Esthetics/Skin Care Education:
    Graduate of Non-COMTA Program             Graduate of COMTA Program              Self-taught
    Extensive Continuing Education            Other:
      Name of school or training program:
       Name:

       Address:

       City/State/Zip:



Involvement in Field of Esthetics and Skin Care: (Check all that apply)
    Employee of Non-COMTA School                        Employee of COMTA School
    Member of Professional Association (specify)        Employer Estheticians
    Presenter of Continuing Education Workshops         Consultant (describe)

Details:

Certified in Esthetics/Skin Care?                      Yes       No         N/A
Certifying body:

Number of Years of Practice in Esthetics/Skin Care:

Number of Years of Teaching in Esthetics/Skin Care:

Areas of Expertise Other Than Massage Therapy/Bodywork or Esthetics/Skin Care:


Experience Receiving Massage Therapy/Bodywork or Esthetics/Skin Care:


Experience Related to Accreditation:


Other Important Experience and/or Qualifications:



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                        Commissioner Candidate Data 2013

Comments:



Signature of Nominee:                  Date:




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