Mailing List Contract Template - Board Of Massage Therapists

Mailing List Contract Template - Board Of Massage Therapists - Oregon

regon

Board of Massage Therapists

728 Hawthorne Ave NE

Salem, OR 97301

Phone: (503) 365-8657

Kate Brown, Governor

Fax: (503) 385-4465

Mailing List Contract

The Oregon Board of Massage Therapists makes available for purchase its mailing list of LMTs that have

given permission for their information to be provided to outside entities. There are approximately 4600 Active

and 400 Inactive LMT’s on the entire list. The actual count may vary due to new and lapsed licenses.

I understand and I agree that the information is provided in an Excel file, is authorized for only one

distribution, and is not to be given or sold to any other individual or company.

Print Name:

_______________________________________

Signature:

_______________________________________

Date: ____________

Please mark the appropriate boxes:

Status

State

Format

Active

Oregon Residents Only

Inactive

All Licensed OR LMT’s*

Email: ____________________________________

Both

*Maintain an OR License and may live in or out of Oregon

Company’s Name:

_________________________________

Phone Number: ___________________

Individual’s Name:

_________________________________

LMT #: _______________

Mailing Address:

_________________________________

City, State, Zip:

_________________________________

By my signature below, I authorize the Oregon Board of Massage Therapists to debit my credit card

or debit card the indicated authorized amount.

_______________________________________

____________________

Signature

Date

Note: Once payment has been processed, please remove this section and shred

Check:

Please circle option:

Visa / MasterCard

(Make payable to OBMT)

Card #: ________________________________ Exp Date: _________

Check #:

__________

V-code: _______ (for Visa only, reverse side of card)

Amount:

$ 100.00_____

Authorized Amount to Charge:

$100.00_

Billing Address of Card: Street #:

_________ Zip Code: _________

(Example: Write 728 for 728 Hawthorne Ave NE. Do not write the entire address.)

Complete and Return to: OBMT 728 Hawthorne Ave NE, Salem, OR 97301 or via fax at 503-385-4465

R06192015EU

Mailing List Contract Template - Board Of Massage Therapists - Oregon

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