BOARD OF MASSAGE THERAPY
Application For Apprenticeship
The mission of the Division of Medical Quality Assurance is to protect and promote the health of all
persons in Florida by diligently regulating health care practitioners and facilities.
Charlie Crist, Governor Ana M. Viamonte Ros, M.D., M.P.H.
State Surgeon General
Revised June 2002
• You must retain the application instructions for your records. Do not send them to the Board
Office with your application.
• Make a copy of everything you send to the Board Office for your own records. You may need to
reference it during the application process.
• Mail the completed ORIGINAL application and fees to the Department of Health at the address
listed in the instructions below.
• Read the entire application package. Most questions will be answered by reading the enclosed
instructions and application.
υ υ υ υ υ υ υ υ υ ATTENTION υ υ υ υ υ υ υ υ υ υ
Before the apprenticeship program may begin, it must be:
• Approved by the Board of Massage Therapy and the Apprenticeship certificate received by the apprentice. Under no
circumstances will any exceptions be granted;
• Under the direct supervision of a sponsoring massage therapist who has been licensed for at least three years. For
colonic programs, the sponsor must also have been certified in the practice of colonic irrigation for at least three (3)
years. The sponsor must be immediately available and on the premises AT ALL TIMES the apprentice will be
performing massage therapy and/or colonic irrigation;
• Conducted in a licensed massage establishment. The establishment MUST be inspected prior to the
commencement of the program to determine compliance with the requirements as set forth in Rule 64B7-29.001(5)
Before The Colonic Apprentice Can Take The Colonic Examination, The Applicant Must:
• Have completed the Colonics Apprenticeship. Meaning the Board office has received the final quarterly report and
verification that you have completed all requirements as specified in Rule 64B7-29.003 F.A.C. and/or Rule 64B7-
29.007 F.A.C. (colonic irrigation) on forms provided by this office, on file with this office;
• submit a fully completed Massage Therapy examination fee and application for the next available Colonic
Examination prior to the deadline established by the Board office. If application and fee are not received before the
deadline, the applicant will have to wait until the next scheduled test. Please, contact the board office for Test dates
and application deadlines, as these are not fixed dates and may be offered at varying times throughout the year.
Before The Apprentice Can Apply For Licensure, The Applicant Must:
• Contact the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) which administers the
National Certification Examination for Therapeutic Massage & Bodywork, the examination currently used in Florida for
licensure of Massage Therapists. Candidates for licensure by examination can apply directly to NCBTMB by calling
1-800-296-0664. The fee for the examination ($225.00) should be paid directly to NCBTMB by all candidates.
• Still file an application for licensure with the Board of Massage Therapy, along with the initial licensure fee of $205.00.
INSTRUCTIONS FOR COMPLETING THE APPLICATION
Where to send the application: The original application accompanied by the applicable fee should be addressed
to the following:
Department of Health
P.O. Box 6330
Tallahassee, FL 32399-6330
Use of this address will ensure receipt of the application and fee(s). After posting of fee(s), the Bureau will forward the
application to the Board of Massage Therapy for processing of the application.
Where to send any additional documentation: Any additional documentation, sent either by the applicant or by
any other source on your behalf, should be mailed to the following address:
Department of Health
Board of Massage Therapy
4052 Bald Cypress Way, BIN C06
Tallahassee, FL 32399-3256
Carefully read the instructions before completing the APPRENTICESHIP APPLICATION.
You must complete and sign The following Sections: Items 1- 27, Affidavit and Photograph
1. Application category: Please check which application category you are applying for in the box provided.
2. Pursuant to s.456.38F.S. & s.381.0303F.S, The Dept of Health is required to ask if you are willing to assist the Dept
in the event of a Disaster. Please, indicate if you are willing or not.
3. ame: List Last, First, and Middle name as it would appear on a birth certificate and/or legal name change
document. Nicknames or shortened versions are unacceptable.
4. Social Security Number: equired. Under the Federal Privacy Act, disclosure of Social Security numbers is
voluntary unless specifically required by federal statute. In this instance, Social Security numbers are mandatory
pursuant to Title 42 United States Code, Sections 653 and 654; and Sections 46.203(9), 409.2577, and 409.2598,
Florida Statutes. Social Security numbers are used to allow efficient screening of applicants and licensees by Title IV-
D child support agency to assure compliance with child support obligations. Social Security numbers must also be
recorded on all professional and occupational license applications and will be used for licensee identification pursuant
to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (Welfare Reform Act), 104 Pub. L. 193,
5. Mailing Address: List the address where correspondence regarding your application should be received. If you
should move during the application process, please notify our office immediately in writing of your new address.
6. Physical Address: f your mailing address is a Post Office Box, please provide the physical location address of your
7. Home and Business Telephone number: Provide telephone numbers at which you may be reached.
8. Name & Mailing Address of Your Nearest Relative: rovide the full name and the mailing address of your nearest
9. Change of Name: If you have legally changed your name through marriage or action of the court, submit all names in
which you have been known
10. Place/Date of Birth, Race/National Origin, Gender, Physical Description, and Drivers license number: We
are required to ask that you furnish the following information as part of your voluntary compliance with Section 2,
Uniform Guidelines on Employee Selection Procedure (1978) 43 FR38296 (August 25, 1978). This information is
gathered for statistical and reporting purposes only and does not in any way affect your candidacy for apprenticeship.
11. Citizenship: Answer yes or no. If no, please complete section 12a.
12. Resident: Answer yes or no. If no, please complete 13a.
rofessional licenses: Answer yes or no. If yes, complete section 14a. Request license verification(s) to be
submitted to the Florida Board of Massage Therapy directly from all State Massage licensing Boards in which you
hold/held a license to practice massage therapy.
APPLICANT HISTORY QUESTIONS:
If questions #14, 15, 16, 17 or 18 are answered “yes”, you must submit the following:
• A detailed statement in your own words explaining your involvement and what happened.
• Each State Board must submit supporting documentation to include, notice(s), complaint(s), charge(s), and
If question #19 is answered “yes”, you must submit the following:
• A detailed statement in your own words explaining your involvement and what happened. Your statement
should include dates, charges, outcome, and current status.
• You must submit certified documentation from the Clerk of Court explaining the circumstances of your arrest,
the sentencing due to your arrest, the current status, and, proof of successful completion of your sentencing.
If questions #20, 21, 22, or 23 are answered “yes”, you must submit the following:
• A written clarification of the reason(s) and date(s) of treatment, listing all
physicians/therapists/counselors/hospitals/institutes where treatment was received.
• Each physician/therapist/counselor is required to submit a report directly to the Florida Board of Massage
Therapy regarding treatment. In addition, list all prescribed medications.
If questions # 24, 25, or 26 are answered “yes”, you must submit the following:
• A detailed statement in your own words explaining your involvement and what happened. Your statement
should include dates and name of employer/educational institution.
If you answered “yes” to an applicant history question on your application, your application may be presented to the Board
for determination of licensure. Once an application is complete, it is forwarded to the designated Board member for
determination as whether your application would need to be presented to the Board. Board staff cannot make this
determination. If your application has to be presented to the Board you will be notified in writing with the date and time of
the next board meeting.
AFFIDAVIT OF APPLICATION: This page should be signed and dated.
PHOTOGRAPH: Attach one (1) 2" X 2" head and shoulder photograph to page three of the application.
The Massage Establishment Owner(s) must complete and sign section: Item 27
Your Sponsor must complete and sign section: Item 28
Do Not Write In This Space
Office Use Only
Massage Apprenticeship Application
State Of Florida Application For Licensure Client 1401
Department Of Health
Board Of Massage Therapy
4052 Bald Cypress Way, Bin C99
Tallahassee, Florida 32399-3299
1. Select Application Category:
Massage Therapy Apprenticeship only Colonic Irrigation Only
(excluding colonic irrigation)
2. Would you be willing to provide health services in special needs shelters or to help staff disaster Yes
medical assistance teams during times of emergency or major disasters? No
3. Name: (First) (Middle Initial) (Last)
4. Social Security Number (Required)
5. Mailing Address: (Street number & Name)
(City , State & Zip Code)
6. Physical Address (Street number & Name)
(City , State & Zip Code)
7. Phone Numbers: (Home Phone Number)
(Business Phone Number)
8. Name & Mailing (Name)
Address Of Your
(Street number & Name)
(City , State & Zip Code)
9. Have you ever changed your name through marriage or through action of a court, Yes
or have you ever been known by any other name? No
(If yes, list name(s) and date(s) of name change(s))
10. We are required to ask that you furnish the following information as part of your voluntary compliance with
Section 2, Uniform Guidelines on Employee Selection Procedure (1978) 43 FR38296 (August 25, 1978). This
information is gathered for statistical and reporting purposes only and does not in any way affect your candidacy
Place Of Birth (City/State/Country) Date Of Birth (Month/Day/Year) Sex: Female
Race And National Origin Caucasian Hispanic
Native American Black Oriental Other:
Physical Description: (Color of Eyes) (Color of Hair) (Height) (Weight)
_____________________________ _____________________________ _____________ _____________
(Other Means of Identification) (Driver’s License Number)
11. Are you a citizen of the United States?
a. If you answered no, which Country do you hold citizenship to? _____________________________
12. Are you a permanent Resident of Florida?
a. If you answer no, what state are you a resident of? __________________________________________
13. Do you now hold or have you ever held any license (medical or professional service) or
certificate of registration to practice massage or any other profession, to practice in any state, Yes
U.S. territory or foreign country? Examples include, but are not limited to Nursing, No
Chiropractic, Facial and Skin Care Specialist, PT, OT, etc.
a. If yes, list state(s), TYPE of license, license number(s), date(s) of issuance, status of license(s) and an
explanation if the license is no longer active: ________________________________________________________________________
If you answer yes to any of the following questions (18-30) please refer to your application
instructions for a list of additional documentation you must submit with your application.
WARNING: (480.046) Attempting to procure a license by fraudulent misrepresentation may
result in disciplinary action.
14. Have you ever been denied the right to take a massage therapy (for any other medical or Yes
personal service) licensing examination in any state or jurisdiction No
15. Have you ever been refused a license to practice massage therapy or any other license - or Yes
renewal thereof- in any state or other jurisdiction? No
16. Have you ever had a license or certificate of registration to practice massage or any other
licensed profession revoked, suspended or otherwise acted against (including probation, fine,
reprimand, or surrender of a license) in a disciplinary proceeding in any state? (licensed profession
examples include, but are not limited to a Nurse, Chiropractor, Facial and Skin Care Specialist, PT,
17. Are you now or have you ever been a defendant in a civil litigation in which the basis of the
complaint against you was an alleged negligence, malpractice, or lack of professional competence,
or sexual misconduct?
18. Is there currently pending against you (in any state or jurisdiction) a complaint against your Yes
professional conduct or competence? No
19. Have you ever been convicted of, or entered a plea of guilty, nolo contendere, or no contest to, a
crime in any jurisdiction other than a minor traffic offense? You must include all misdemeanors and
felonies, even if the court withheld adjudication so that you would not have a record of conviction.
Driving under the influence or driving while impaired is not a minor traffic offense for
purposes of this question
20. In the last 5 years, have you been enrolled in, required to enter into, or participated in any drug Yes
or alcohol recovery program or impaired practitioner program? No
21. In the last 5 years, have you been treated for or had a recurrence of a diagnosed mental disorder Yes
or impairment? No
22. In the last 5 years, have you been treated for or had a recurrence of a diagnosed physical Yes
23. In the last 5 years, have you been treated for or had a recurrence of a diagnosed addictive Yes
24. Have you been fired from, or asked to leave, or had disciplinary action taken against you in any Yes
job within the seven years preceding this application? No
25. Have you been absent from school or a job for more than thirty consecutive days without Yes
approved leave within the five years preceding this application? No
26. In the last five years, have you been expelled, suspended from, or had disciplinary action taken Yes
against you by an educational institution? No
AFFIDAVIT OF APPLICATION: I, ___________________________________________________affirm that I am the
person referred to in the foregoing massage therapy licensure application, and that the attached photograph is a true
likeness of myself.
I understand that it is my duty and responsibility as an applicant for licensure to supplement my application after it has
been submitted if and when any materials change in circumstances or conditions occur which might affect the Board’s
decision concerning my eligibility for apprenticeship. Such supplement is required by Chapter 456.213(1), F.S. Failure to
do so may result in disciplinary action by the Board including denial of licensure.
I have carefully read the questions in the foregoing application and have answered them completely, without reservation
of any kind, and I declare that my answers and all statements made by me herein are true and correct. Should I furnish
any false information on this application, I understand that such action shall constitute cause for denial, suspension, or
revocation of any license to practice in the state of Florida in the profession for which I am applying. I have read,
understand and agree to comply with the statutes and rules applicable to the practice of my profession in Florida.
I understand the application fee is non-refundable.
Applicant Signature: ______________________________________________________________________
Date Signed: ____________________________________________________________________________
27. To Be Completed By The Establishment Owner
A.) Has your establishment been inspected within the last 12 months? Yes
If yes, Date of Inspection:______________________________ No
B.) Is your establishment equipped with tables for massage therapy?
C.) Is your establishment equipped with linen and storage areas?
D.) Is your establishment equipped with the following hydrotherapy equipment:
• Hot and Cold packs?
AND at least one of the following:
• Steam room or cabinet
• Sauna Yes No
E.) Is your establishment equipped with textbooks and teaching material on the following subjects:
• Physiology Yes No
• Anatomy Yes No
• Theory of Massage Yes No
• Hydrotherapy Yes No
• Statutes and Rules on Massage Practice Yes No
F.) Will the apprentice be instructed in colonic irrigation (optional)? Yes No
If yes, the following must be answered:
• Is your establishment equipped with sterilization equipment? Yes No
• Are disposable colonic attachment utilized? Yes No
• Is a textbook on the subject of colonic irrigation kept on the Yes No
G.) Has the massage establishment, or owner, ever been convicted of a crime related to the practice
of massage therapy, regardless of adjudication, or has the massage establishment license ever been
disciplined, in any jurisdiction? If yes, please list and attach on additional sheets, the dates, Yes No
jurisdiction, offense, disposition, and all other relevant information
You will be inspected based on the above items. If you cannot answer “yes”
to all applicable questions, you are urged to make immediate changes in order to pass inspection or
delay the application for this apprentice until your facility is able to pass inspection.
I, ________________________________, certify that ____________________________, employed at
(Name of establishment representative) (Name of Sponsor)
_______________________________________ establishment license #_MM____________ located at
(Name of Establishment)
___________________________________________________________________ has my approval to sponsor
(Street Address - City, State, Zip Code, Phone #)
an apprentice at the above named establishment.
_______________________________ _____ ______________________________________________
(Signature of Establishment Representative) (Printed Name of Establishment Representative)
28. To Be Completed By Sponsor
I, _______________________________________________________________, hereby certify that the previously
named applicant will be associated with my practice and establishment, as an apprentice, and I will be his/her sponsor
and I will comply with all requirements pursuant to Rule 64B7-29 F.A.C.
Have you, the sponsor, ever had a massage therapist license, registration or certification
revoked, suspended or otherwise acted against, including probation, fine or reprimand in a No
disciplinary preceding in any state?
If yes, you must provide complete details as to the state(s), license number(s), dates and relevant
circumstances on an attached sheet.
C.) Sponsor’s Printed Name:
D.) Sponsor’s License Number:
E.) Sponsor’s Signature and Date