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First Name Last Name
Address City
State Zip Code
Phone # -- Email
License # Years in Practice
What course are you most interested in?
Why is Continuing Education important to you both professionally & personally? (250 words maximum)
What interests you about the OMERI e-Learning program? (250 words maximum)
What are your particular challenge(s) in gaining access to Continuing Education? (250 words maximum)
Please list your top three massage products (product name & brand) and what you like about them.
What additional topics would you like to see covered in a CE Workshop?
Please review your application before pressing the 'Send Application' button.

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