APPLICATION FOR MASSAGE CONTINUING EDUCATION (CE) FOR INTEGRATED ENERGY THERAPY® (IET) CLASSES Name of Applicant: _______________________________________________ (Please Print) Mailing Address: (Street) ___________________________________________ (City) ____________________________________________ (State) __________________________ (Zip) ____________ NCBTMB Identification: State ______ NCBTMB ID: ______________ Email: ___________________________________________________________ Phone Number: __________________________________________________ Name of Class and Date Completed (Furnish dates of completed classes only): Basic Level Integrated Energy Therapy ______________________ (8.0 CE) Intermediate Level Integrated Energy Therapy __________________ (8.0 CE) Advanced Level Integrated Energy Therapy _____________________ (8.0 CE) Integrated Energy Therapy for Pets ____________________________ (8.0 CE) Integrated Energy Therapy Master Instructor ____________________ (16.0 CE) Name as you wish for it to appear on your certificate: Name of IET Master-Instructor: ___________________________________________ Signature of IET Master-Instructor: ________________________________________ (Please mail your completed form along with a check in the amount of $15.00 to The Center of Being, Inc., PO Box 883, Woodstock, NY 12498)