□ Allen (972) 649-4228 | allen@elementsmassage.com
Date: _______________________
APPLICATION FOR EMPLOYMENT
General Information
Last Name
Address
Primary Contact Phone #
First Name
City
MI
(Maiden Name/Other)
State
Email
Zip Code
Secondary Contact Phone #
Do you have a current Driver’s License?
   Yes, State: __________________________
  DL#: _______________________________
  Class: ______________________________
   
No
Do you have any relatives working for Elements
Therapeutic Massage?
    No     Yes, name:___________________
Relationship:__________________________
Have you ever worked for Elements Therapeutic
Massage?
  Yes. Dates:____________ to ____________
Position:________________________________
No
If hired, can you furnish proof that you are legally
entitled to work in the US?
                 Yes            No
Are you least 16 years of age?
                Yes            No
Availability
Position(s) you are applying for:
Interested in:        Full Time        Part Time      Temporary
I will accept:         Full Time       Part Time       Temporary
Date Available:__________________________________
   Dates
FromTo
Education
School
HIGH
SCHOOL:
TRADE
SCHOOL:
COLLEGE:
OTHER:
Name & Location
Diploma or GED?
Credit Hours & Major
Yes
No
Certificate/Degree obtained
Major / Minor
Certificate/Degree obtained
Major / Minor
DF/14
This Elements Massage franchise is independently owned and operated by DVD BIS, LLC.
Page 1 of 6

Skills
List all types of computers and software programs you have experience with:
License, Certificates & Certifications:
Honors, Recognition, other Skills and Training:
Languages
______________
______________
Read
Read
Speak
Speak
Write
Write
Criminal History
Elements Massage conducts criminal history checks on all employees.
Answer following question in full:
(Note: A conviction does not mean that you will not be considered for employment. Your age, date of offense, nature of the
       violation and rehabilitation will be taken into account.)
Have you ever been convicted, placed on deferred adjudication or community supervision, or
Pled guilty or no contest to a felony or misdemeanor offense? (Other than to class C traffic violations as listed above)
Yes
No
If NO, mark No and skip this section. If YES, please answer the following questions about each
conviction.
Arrested: Dates: _______________ Locations: _________________________________________
What were your charges: ____________________________________________________________
Results:
       Probation or Deferred Adjudication:
               Starting dates: ____________________ Finishing dates: _____________________
       Jail or Prison Sentence:
               Starting dates: ____________________ Finishing dates: _____________________
       Fine: Amounts $____________________
Please use the back page of this application form to give more information or use a separate sheet and attach to this
application.
Work Experience (Beginning with the most recent)
1. Employer
Address
Telephone
    Dates
FromTo
Duties
DF/14
This Elements Massage franchise is independently owned and operated by DVD BIS, LLC.
Page 2 of 6

Work Experience (Beginning with the most recent)
Your Job Title
Supervisor
Reason for Leaving
2. Employer
Address
Telephone
Your Job Title
Supervisor
Reason for Leaving
3. Employer
Address
Telephone
Your Job Title
Supervisor
Reason for Leaving
 Wage/Salary
StartEnd
    Dates
FromTo
Duties
 Wage/Salary
StartEnd
    Dates
FromTo
Duties
 Wage/Salary
StartEnd
(continued)
If you are currently employed, may we contact your employer?
Yes
No
Future Education
Are you planning to pursue further studies?      Yes            No
If yes, when, where, what and what courses?
_________________________________________________________________________________
_________________________________________________________________________________
List any organizations you belong to, Hobbies, or Special Interests
DF/14
This Elements Massage franchise is independently owned and operated by DVD BIS, LLC.
Page 3 of 6

Read Carefully Before Signing
I certify that all the answers I have given are true to the best of my knowledge and belief. I understand
that any falsifications, misrepresentations or omission of facts in this application may be cause for my
elimination from consideration for hire, or, if already hired, cause for my dismissal, regardless of the
time that passes before such false information is discovered. I further acknowledge that I have read
and understand the questions regarding criminal records and I have answered these questions
truthfully. I expressly request employers and any persons who may have information (including
records of criminal convictions) concerning me, furnish that information to the Human Resources
Department and agree to hold such persons harmless, and I do hereby release them of any and all
liability or damage of any nature whatsoever for furnishing such information. I understand that the
information obtained is for Elements Massage use and may be disclosed to third parties as required
by law.
I understand that I may be required to complete a physical examination and drug/alcohol screening, at
Elements Massage’s expense, after a conditional offer of employment. If a doctor determines I have
certain medical restrictions relating to my ability to perform the job I applied for, those restrictions will
be communicated to the Human Resources Department of Elements Massage for the purpose of
determining my ability to perform the essential functions of the job with or without any
reasonable accommodation. I understand and agree that employment with Elements Massage is
"at will" and for no definite period of time and that wage, benefits and conditions of
employment can be changed at any time. I understand that this is not an employment contract
between Elements Massage and me. Elements Massage will reject any application which is
unsigned or graphically altered.
Signature: _______________________________________ Date: ____________________________
Note/additional information
DF/14
This Elements Massage franchise is independently owned and operated by DVD BIS, LLC.
Page 4 of 6

Therapist Application Questionnaire
Name: _______________________________ Date: ____________________
1. A client complains of low back pain. You have massaged their low back and gluteus muscles and they
   are still in pain. What other muscle(s) should you address?
____________________________________________________________________________
____________________________________________________________________________
2. You have a client who works on the computer all day. They have significant upper back, neck and
   shoulder pain. What muscle groups are you going to be sure to massage?
____________________________________________________________________________
____________________________________________________________________________
3. A client complains of a tension headache. Which muscle groups/areas of the body are you going to be
   sure to address first?
____________________________________________________________________________
____________________________________________________________________________
4. A client has a migraine headache. How will you address this in your massage? What instructions will you
   give them for easing the migraine at home? Heat/Ice? Where? Pressure points they can active? Where?
____________________________________________________________________________
____________________________________________________________________________
5. A client has been in an automobile accident. How soon after the accident would you give their first
   massage? Would you recommend chiropractic treatment?
____________________________________________________________________________
____________________________________________________________________________
6. The same client has suffered whiplash during the automobile accident. What muscle(s) (besides the
   sternocleidomastoid) would you address?
____________________________________________________________________________
____________________________________________________________________________
7. With a prenatal client what is the best positioning after 22 weeks? What areas should you not
massage? Why would deep tissue massage be contraindicated?
____________________________________________________________________________
____________________________________________________________________________
DF/14
This Elements Massage franchise is independently owned and operated by DVD BIS, LLC.
Page 5 of 6

EEOC Statement
Elements Massage is an equal opportunity employer. The commitment of Elements Massage
is to a policy of equal employment opportunity requires that certain information be gathered and
documented for statistical purposes only. The following information is requested for Human
Resources use only in order to assist us in complying with EEO reporting guidelines. This information
will be kept separately from the applicant's files and will not be used as a basis for making
employment or upon employment will not be used for any subsequent personnel decision.
This form is optional
Ethnic Group
having origins in any of the original peoples of
Europe, North Africa or the Middle East.
having origins in any of the Black racial groups
of Africa.
Rican, Cuban, Central or South American, or
other Spanish culture or origin.
White (Not of Hispanic origin) - All persons
Black (Not of Hispanic origin) - All persons
origins in any of the original peoples of the Far
East, Southeast Asia, the Indian Subcontinent,
or the Pacific Islands. This area includes, for
example, China, India, Japan, Korea, the
Philippine Islands and Samoa.
persons having origins in any of the original
peoples of North America, and who maintain
cultural identification through tribal affiliation or
community recognition.
Asian or Pacific Islander - All persons having
American Indian or Alaskan Native - All
Hispanic - All persons of Mexican, Puerto
Other
Sourcing Information
Please complete the following information to help us determine our advertising effectiveness. You
heard about this position from:
   Elements Website
   Friend/Family
   University Career Services
   Massage School
       
School Name:
________________________
________________________
Dallas Morning News
Ft. Worth Star Telegram
Library
Professional
Craigslist.com
Monster.com
Jobing.com
Salonpost.com
Other (be specific): ____________________________________
DF/14
This Elements Massage franchise is independently owned and operated by DVD BIS, LLC.
Page 6 of 6