Title

First Name

Surname

Address line 1

Address line 2

Address line 3

Town/city

Postcode

County

Email address

Website address (if applicable)

Home telephone

Mobile telephone

Date of birth

What qualifications do you have? Please list qualifications (most recent first) and enter the name of school(s / college(s) where obtained for each.

What are your preferred working days? Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Preferred time of day to work? Mornings Afternoons Evenings

Please list treatments you provide? For each treatment you provide, list the timescales they can be performed within (e.g. 15/30/45 mins)

Where do you provide your treatments? From my home At a salon Both

Can you provide your own equipment? If yes, please specify what equipment you can provide.

Do you have your own transport? Yes No

How far would you travel for work? 0-5 miles 6-10 miles 11-20 miles 20+ miles I do not wish to travel

Do you have liability insurance? Yes No

Please state your insurer

Please state your policy number

When does your policy expire?

Do you have any criminal convictions? If yes, please give details and include nature of offence(s) and dates.

Any claims been brought against you? If yes, please give details including any claims pending regarding your work as a therapist.

Best time of day to contact you? Mornings Afternoons Evenings Weekdays Weekends

How did you hear about us? Friend/colleague recommendation Search engine (e.g. Google) Received a mailing Received an email Read an article Saw an advertisement Attended event / exhibition

Declaration I AGREE with declaration below I DISAGREE with declaration below