Commissioner Candidate Data 2014
Commissioner Candidate Data 2014
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:
Public Member
Esthetics Practitioner / Regulator
Distinguished Contributor
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:
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:
Comments:
Signature of Nominee: / Date:
Additional confirmation for Public Member candidates:
Please review the Confirmation of Public Member Eligibility and submit the signed affidavit.
Page 1 of 3