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BROOKLYN INSTITUTE OF MASSAGE THERAPY
1145 60th Street, Brooklyn, NY 11219
Telephone: (718) 853-8606
Recent Photo Here APPLICATION
New Student: ____ Transfer Student: ____ Non-Matriculate Student: ____
PERSONAL DATA: Mr: ____ Ms: ____
Name:________________________________________________ SS#: ____________________________
Last Name First M.I.
Date of Birth: ______/_____/_____ Place of Birth: __________________________________________
Month Day Year City State or Country
Home Phone:__________________________________ Email: _________________________________
Address:____________________________________ City: __________ State:___ Zip Code_________
In case of Emergency, notify: Name: ____________________________________________________________
Address:_____________________________________City:___________ State: ___ ZipCode _________
Relationship: ___________________________ Telephone #: ___________________________________
Applying for the Quarter beginining :__________________________ ; of Year 20________
EDUCATIONAL BACKGROUND:
________________________________________________________________________________________________
High School Street City State Zip Code
Date Attended:________________________ Year of Graduation:_______________
Diploma:__________________ or GED: ______________ or Other: __________________
New York State requires BIMT to have on file an official copy of your High School
transcript. Applications will not be processed until an official transcript has been
received by the Institute.
List other post secondary schools you attended, if any.
________________________________________________________________________________________________
College/Univ/Tech School Street City State Zip Code
Dates Attended:_________________________ Year of Graduation:_________
Have you ever been convicted or pled guilty or no contest to a felony or a
misdemeanor?
No:_____ Yes: _____ (Please attach explanatory statement)
ESSAY
Please write an essay describing your purpose for enrolling at BIMT, expressing your personal and professional goals related to this field of study. Include, any experiences you may have had in the past. Lastly, any difficulties you may have at the present. You must submit this information on a separate sheet of paper either typed or handwritten, neatly along with this application.
_______________________________________________________________________________________________
PLEASE LIST TWO REFERENCES
1.______________________________________________________________________________________________
First Name Last Name Telephone #
Address: _______________________________________________________________________________________
2.______________________________________________________________________________________________
First Name Last Name Telephone #
Address: ______________________________________________________________________________________
Do you have any physical conditions that may hinder your ability to perform the
challenging work of massage? Circle Y / N If yes,
explain:________________________________________________________________________________________
_______________________________________________________________________________________________
Have you ever been dismissed from an educational institution or training program?
Circle Y / N If yes, explain:________________________________________________________________________________________
_______________________________________________________________________________________________
APPLICATION CHECKLIST: ( ) Completed application ( ) Copy of Drivers license
( ) Four passport photos ( ) $ 50.00 Application Fee (Non-refundable)
( ) Official High School and/or College Transcripts sent directly from colleges and or
schools previously attended.
( ) Two letters of recommendation mailed directly to the Institute ( ) Essay
THE APPLICATION FOR ADMISSIONS WILL NOT BE PROCESSED UNTIL THE$ 50.00 APPLICATION FEE HAS BEEN SUBMITTED.
DECLARATION: I HEREBY CERTIFY THAT ALL THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I ALSO UNDERSTAND THAT PROVIDING FALSE INFORMATION IS GROUNDS FOR DISMISSAL FROM THE INSTITUTE. ALL
APPLICATION DOCUMENTS SUBMITTED TO BIMT SHALL BECOME THE PROPERTY OF THE INSTITUTE.
_________________________________________________________ ________________________
SIGNATURE OF APPLICANT Date
________________________________________________________________________________________________
If my application is accepted, I agree to pay the current tuition charges and fees. I also agree to abide by all the Policies, Rules and Regulations of the Institute.
Brooklyn Institute of Massage Therapy does not discriminate against any individual on the basis of age, sex, race, color, religion, marital status, national, ethnic origin, sexual orientation or handicap in the admissions of students.
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