Thank you for your interest in the Interstate Massage Compact. Please complete the following to help us understand both you and your needs/desires. We know your time is valuable and we appreciated your commitment to the massage profession! For more information prior to completing this survey please visit massagecompact.org

* Individual data collected, such as name and contact information, will not be shared and is only being collected to support the integrity of the survey, to reply to questions asked by you within the survey, and to contact you regarding activity in your home state as you designate in response to question 11. If you have any questions please email Patty Glenn, FSMTB Director of Education and Professional Mobility, at pglenn@fsmtb.org. Thank you!

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* 1. First Name:

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* 2. Last Name:

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* 3. Email:

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* 4. Phone Number:

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* 5. Business/Organization Name:

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* 6. I am a Massage: (Check all that apply)

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* 7. Please select your US state or territory of legal residence: (Where you are registered to vote)

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* 8. Massage Therapists: Please check all states/territories in which you are currently licensed/certified/registered to practice massage:

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* 9. Professional Membership / Affiliations:

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* 10. Please select the response that best fits your position on the IMpact:

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* 11. There are many ways you can help enact the IMpact in your state, please check all the areas you are willing and able to assist in this effort:

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* 12. Please list any other comments or questions here:

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