Name:_________________________________________________________ Title(s):_________________

Business/Trade Name:___________________________________________________________________

Address :______________________________________________________________________________
..........................Streett................................................................................................................................Apt

______________________________________________________________________________________
City/town.....................................................................................................................State..............................ZIP

[Mailing Address if different from above]

Address :______________________________________________________________________________
..........................Street/PO Box...........................................................................................................................

______________________________________________________________________________________
City/town.....................................................................................................................State..............................ZIP

__ M __F [optional]  Age [optional] ____ (D.O.B.) [optional]_______________  Height________ Weight________

Telephone: (W)________________ (H)________________ (C)______________ E-mail_________________

Website(s)______________________________________________________________________________

Position Applied for:
Transpersonal Psychiatric/psychological therapist q [specify modality or modalities on separate sheet]
Massage/Physical therapist q [specify modality or modalities on separate sheet]
Yoga q   Qi Gong q   Tai Chi q   Aikido q   Aerobics q   Nia q   Dance/Movement q  Za-Aen q Acupuncture q    Shiatsu/Acupressure q   Breathwork q    Nutrition q   
Other q [use additional sheet of paper if needed]
 

Personal History

Have you had any criminal convictions, felony or misdemeanor ?  

__ No

__ Yes [describe other than minor traffic violations] _______________________________________________

_________________________________________________________________________________________

__Single,  __Married [or living together], __ Separated, __Divorced, __Children (how many___)

Have your professional privileges, certification or license ever been revoked or suspended?

__ No

__ Yes [describe circumstances, and when]  _____________________________________________

____________________________________________________________________________

Do you have any physical or mental/emotional handicaps that might affect any of the programs conducted by A Cup of Tea?
[include any alcohol or drug related issues, bad back, obesity, allergies, hypertension, phobias, etc.]

__ No

__ Yes [describe]: ____________________________________________________________

References (Personal and/or business)
[Please include 5 people, with 2 who have known you professionally for at least 5 years]

Name: ______________________________________________________________________________

Address:____________________________________________________________________________

Telephone: ____________________ Affiliation: _____________________________________________

Name: ______________________________________________________________________________

Address:____________________________________________________________________________

Telephone: ____________________ Affiliation: _____________________________________________

Name: ______________________________________________________________________________

Address:____________________________________________________________________________

Telephone: ____________________ Affiliation: _____________________________________________

Name: ______________________________________________________________________________

Address:____________________________________________________________________________

Telephone: ____________________ Affiliation: _____________________________________________

Name: ______________________________________________________________________________

Address:____________________________________________________________________________

Telephone: ____________________ Affiliation: _____________________________________________

Education:

High School

Dates: From_______ to ________

Name:_____________________________________________________________________

Address:___________________________________________________________________

College 

Dates: From_______ to ________

Name:_____________________________________________________________________

Address:___________________________________________________________________

___Non-matriculated [optional]

___Matriculated (Number of credit hours)_____      

Studies: _________________________________________________________

Degree: Type_______ in ____________________________________________

Post Graduate

Dates: From_______ to ________

Name:_____________________________________________________________________

Address:___________________________________________________________________

Studies: _________________________________________________________

Degree: Type_______ in ____________________________________________

Other Post Graduate

Dates: From_______ to ________

Name:_____________________________________________________________________

Address:___________________________________________________________________

Studies: _________________________________________________________

Degree: Type_______ in ____________________________________________

Other [optional]
[including spiritual affiliation, master, sensei or self-taught]

Description:________________________________________________________________

Name: ____________________________________________________________________

Address:___________________________________________________________________

Other 

Description:_________________________________________________________________

Name:_____________________________________________________________________

Address:___________________________________________________________________

Other 

Description:________________________________________________________________

Name:_____________________________________________________________________

Address:___________________________________________________________________
[use additional sheet of paper if needed]

License(s)

Description_________________________________________________________ Date __________

Description_________________________________________________________ Date __________

Description_________________________________________________________ Date __________

Certification(s) 

Description_________________________________________________________ Date __________

Description_________________________________________________________ Date __________

Description_________________________________________________________ Date __________

CEU's obtained the past 18 months

Description_____________________________________________Unit value____ Date __________

Description_____________________________________________Unit value____ Date __________

Description_____________________________________________Unit value____ Date __________

How many courses, workshops or classes have you taught?________

What__________________________ Where___________________________ When_____________

What__________________________ Where___________________________ When_____________

What__________________________ Where___________________________ When_____________

What__________________________ Where___________________________ When_____________

(more...)
[provide references and contact info]

Employment
[part-time, self-employed or volunteer) starting with most recent, use additional paper if necessary.] 

Name: ___________________________________________________________________________

Address:__________________________________________________________________________

Job Title:______________________ Duties (in detail):_____________________________________

_________________________________________________________________________________

Started__________ Finished__________, Still work for them___ [Part time, ___ Full time___]

Name: ___________________________________________________________________________

Address:__________________________________________________________________________

Job Title:______________________ Duties (in detail):_____________________________________

_________________________________________________________________________________

Started__________ Finished__________, Still work for them___ [Part time,___ Full time___]

Name: ___________________________________________________________________________

Address:__________________________________________________________________________

Job Title:______________________ Duties (in detail):_____________________________________

_________________________________________________________________________________

Started__________ Finished__________, Still work for them___ [Part time,___ Full time___]

Name: ___________________________________________________________________________

Address:__________________________________________________________________________

Job Title:______________________ Duties (in detail):_____________________________________

_________________________________________________________________________________

Started__________ Finished__________, Still work for them___ [Part time,___ Full time___]

(more...)

In your own words, what do you feel, think or believe your work is about?_________________________

_____________________________________________________________________________________
[use additional sheet of paper if needed]

Publications 
[books, papers, articles, videos, tapes, CDs you have authored, co-authored, or produced]

Name____________________________________________________________________________

Publisher or Publication:_____________________________________________________________

Name____________________________________________________________________________

Publisher or Publication:_____________________________________________________________

Name____________________________________________________________________________

Publisher or Publication:_____________________________________________________________

[use additional sheet of paper if needed]

Personal Appearances (interviews on TV, radio, print, Internet, plus personal lectures, etc.) 

[use additional sheet of paper if needed]

Biography [optional]
Here include a narrative sketch of your life from childhood. Include life experiences, Including the bad and the good. What do others think of you? What have you learned? What have you taught? What are your joys? Dislikes? What do you feel you have achieved? Include any and all spiritual, holistic, metaphysical pursuits, plus hobbies, travel, etc. 
[use additional sheet of paper]

You may send this as e-mail, or by regular mail: A Cup of Tea, PO Box 17397, Asheville, NC 28816,  Telephone: 828-254-6620. This application will be held in strictest confidence, be we assume no liability or responsibility for any confidentiality, nr does submission of this application does not grant certification.

© 2006, A Cup of Tea, all rights reserved.