STATE OF FLORIDA
BOARD OF MASSAGE THERAPY
APPLICATION FOR LICENSURE
Board of Massage Therapy
4052 Bald Cypress Way, Bin # C-06
Tallahassee, FL 32399-3256
Revised January 2006
TABLE OF CONTENTS
Section I: General Information/Instructions
Section II: Application
Section III: Criminal Conviction Form/Instructions
υ υ υ υ υ υ υ υ υ ATTENTION υ υ υ υ υ υ υ υ υ υ
• Please 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. You may need to reference it during the
• Read all instructions thoroughly before completing the application.
• Mail the completed ORIGINAL application and fees to the department at the address noted in the
• Keep a copy of the completed application for your records.
• Read the entire application package. Most questions will be answered by reading the enclosed
instructions, application, and supplemental documentation forms.
GENERAL INFORMATION / INSTRUCTIONS
Please read the following COMPLETELY before attempting to complete the application, as this information is
provided to assist you in expediting the application process.
Certain applicants may be required to appear before the Board to discuss their application or may be referred to the
Professionals Resource Network (PRN) for an evaluation of competency to practice before a determination of licensure
can be made. An appearance, PRN referral or combination of both may be required for a variety of reasons, such as (but
not limited to):
▪ Criminal Convictions
▪ Previous Discipline
▪ Previous appearance before a licensing board or regulatory agency
▪ Drug/alcohol addiction/impairment
▪ Discrepancies in application information/materials
▪ Participation in an impaired practitioner program
▪ Other reasons as deemed necessary by Board staff or the Board Chair
The scenarios listed above are not an automatic appearance before the Board or PRN referral. Appearances and PRN
referrals are determined on an individual basis. The Board’s History Liaison, not office staff, determines the necessity of
an appearance/referral. The History Liaison, at his/her discretion, may also require an application be presented to the
Board for review, but not require the appearance of the applicant. Should your appearance or referral be required, you
will be notified in writing.
In the event that you feel you might be required to appear or be referred to PRN based on the scenarios listed above, it is
imperative that you adhere to the deadlines listed below. The Board only meets quarterly; therefore in order for your
application to be considered by the Board, you MUST have your application in the Board Office by the deadline dates
listed below. Because applications are often deemed incomplete upon initial review, which may take up to 30 days, it is
recommended that you submit your application at least sixty (60) days prior to the meeting for which application is made.
The deadline for COMPLETION of your application is no less than 5 weeks prior to the Board’s meeting. Note: if you are
referred to PRN for an evaluation, your licensure recommendation (from PRN) would need to be in the Board office by the
completion deadline in order to be presented to the Board at that meeting.
It is very important that you understand the necessity of these dates. These dates and deadlines are published so that
you may make licensure plans accordingly. Please refrain from making any commitments or accepting positions to
practice massage therapy in Florida, as exceptions and/or special accommodations can not be made. It is IMPERATIVE
that you adhere to the dates that are listed for your convenience.
YEAR 2006 MEETING SCHEDULE
(Dates/locations are subject to change)
Required Application AGENDA
COMPLETION Deadline Deadline
January 26-27, 2006
December 19, 2005 December 26, 2005
Tampa Bay Area
April 27-28, 2006
March 20, 2006 March 27, 2006
July 27-28, 2006
June 20, 2006 June 27, 2006
October 26-27, 2006
September 19, 2006 September 26, 2006
WPB, Naples or Ft. Lauderdale
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 the above address will ensure receipt of the application and fee(s).
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
No application will be considered complete until the following supporting documentation has been received in
the Board office:
• A completed application, with all questions answered. Failure to provide an answer to every question will
result in the application being deemed incomplete.
• One current photograph of the applicant
• An official transcript from a Massage Therapy school approved by the Florida Board of Massage Therapy or
completion of a Board Approved Apprenticeship program. Please request your massage therapy school
or the sponsor of your apprenticeship program to submit your transcript or apprenticeship
verification form, whichever is applicable to the “additional documentation” address listed above. If
you did not attend a Florida Board Approved Massage Therapy School, you may have your previous
massage therapy education evaluated by an approved school by taking your transcript and the enclosed
Transfer of Credit Form to an approved school for evaluation. Once your transcript has been evaluated and
the Florida Board approved school determines you meet the education requirement pursuant to 64B7-32.003,
F.A.C., you may submit your application for licensure along with your officially completed Transfer of Credit
Form (which can be obtained from the Board Approved School).
• Proof of completion of a Board approved (2) hour Medical error prevention course. If the course is not
reflected on your school transcript then you must submit verification separately. If you have questions as to
whether you completed these courses, please contact your school.
• Proof of passage of the National Certification Examination for Therapeutic Massage and Bodywork
(NCETMB). Candidates for licensure must apply directly to NCBTMB by calling 1-800-296-0664 to
request an application. The fee for the examination, which is $225.00, should be paid directly to
NCBTMB. Exam scores for Florida candidates only will be electronically submitted to the Florida Board of
Massage Therapy. If you are not a Florida resident when sitting for the exam, you must have your scores
mailed directly from NCBTMB to the Board office using the “additional documentation” address listed above.
• You must also request an official license verification(s) to be submitted to the Board directly from all State
licensing Boards in which you hold/held any healthcare or massage therapy license.
• If you have legally changed your name through marriage or action of the court you must submit all names in
which you have been known and submit a copy of a marriage or divorce decree or other court document
reflecting the legal name change.
• Additional documentation may be required or requested based on affirmative answers to certain questions on
the application. This is noted next to the corresponding question in the application.
Make check or money order payable to the Department of Health
Initial Licensure: $205.00 ($50 application fee (non- refundable), $150 initial license & $5- Combat
Do Not Write In This Space
Office Use Only
Massage Therapy 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:
Licensure by Exam Licensure by Endorsement Date of National Exam
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. Have you ever changed your name through marriage or through action of a court, Yes No
or have you ever been known by any other name?
If yes, list name(s) and date(s) of name change(s):
9. 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 licensure.
Place Of Birth (City/State/Country): Date Of Birth (Month/Day/Year): Sex: Female Male
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)
10. Are you a citizen of the United States?
a. If you answered no, which Country do you hold citizenship to? _____________________________
11. Are you a permanent Resident of Florida?
a. If you answer no, what state are you a resident of? __________________________________________
12. Do you now hold or have you ever held any license (medical or professional service) or
certificate of registration to practice massage therapy or any other profession, in any state, U.S. Yes No
territory or foreign country? (e.g.: Nursing, Chiropractic, Facial and Skin Care Specialist, Physical Therapist,
Occupational Therapist, 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: ________________________________________________________________________
13. Massage Therapy Diploma or certificate was obtained from: ____________________________________________________
Dates Attended: ________________________ Total Number of Hours Completed: _______________
Is this a Florida Board Approved School?
14. If you attended an Apprenticeship program:
Name of Sponsor: ___________________________________________________________________________________
Total Number of Instruction Hours Completed: _____________________________________________________
Please be advised that failure by the applicant to provide the supporting documentation and information, at the time the
application is filed, could lead to a delay in the processing of the application, including but not limited to a required
appearance before the Board, referral to PRN or any other measure authorized by law.
If you answer “yes” to any of questions 15-19 below, you must provide the following WITH the application at the time of
1. A statement explaining in your own words the complete details as to the state(s), license number(s) and relevant
2. A copy of all documentation from the state(s) regarding the incident, including the complaint and final action.
15. Have you ever been denied the right to take a massage therapy (or any other medical or
personal service) licensing examination in any state or jurisdiction
16. Have you ever been refused a license to practice massage therapy or any other professional
license - or renewal thereof- in any state or other jurisdiction?
17. Have you ever had a license or certificate of registration to practice massage therapy or any
other licensed profession revoked, suspended or otherwise acted against (including probation, fine,
reprimand, or surrender of a license) in a disciplinary proceeding or in response to an investigation in
any state? (i.e.: Nurse, Chiropractor, Facial/Skin Care Specialist, Physical Therapist, Occupational Therapist etc.)
18. 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, Yes No
or sexual misconduct?
19. Is there currently pending against you (in any state or jurisdiction) a complaint against your
professional conduct or competence?
If you answer “yes” to question 20 below, you must provide the following WITH the application at the time of submission:
1. Completion of the attached Criminal History Form, on which you must provide all relevant details.
2. Certified documentation from the Clerk of Court pertaining to the arrest/charges, sentencing due to the arrest
and proof of successful completion of your sentencing.
20. 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. Yes No
Driving under the influence or driving while impaired is not a minor traffic offense for
purposes of this question.
If you answer “yes” to any of questions 21- 24 below, you must provide the following WITH the application at the time of
1. A complete description of all treatments and diagnoses you received for any condition/impairment you
experienced or were treated for, including all medications prescribed and all physicians/counselors seen.
2. A statement from your treating physician/counselor for each condition you were or are being treated for, including
all DSM IIIR / DSM IV, Axis I, II and III diagnoses.
21. In the last 5 years, have you been enrolled in, required to enter into, or participated in any drug
or alcohol recovery program or impaired practitioner program?
22. In the last 5 years, have you been treated for or had a recurrence of a diagnosed mental disorder
23. In the last 5 years, have you been treated for or had a recurrence of a diagnosed physical
24. In the last 5 years, have you been treated for or had a recurrence of a diagnosed addictive
If you answer “yes” to question 25 below, you must submit the following WITH your application at the time of submission:
1. A statement indicating the details surrounding the instance, including the institution name and address and
2. A statement from the institution regarding the incident and outcome.
25. In the last five years, have you been expelled, suspended from, or had disciplinary action taken
against you by an educational institution other than your high school?
AFFIDAVIT OF APPLICATNT: 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 material change in circumstances or conditions occur which might affect the Board’s decision concerning my eligibility for
examination or licensure. Such supplement is required by Chapter 456.013(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 and in support of this application are true and correct. Should I
furnish any false information on or in support of 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. TAPE 2x2
Applicant Signature: ______________________________ PHOTOGRAPH
Date Signed: ________________________________ HERE
CRIMINAL HISTORY FORM
This form must be completed if you answer “yes” to question #20 on the application. Please complete a separate form for
EACH offense. You may duplicate this form as necessary.
Social Security Number: ______________________________________________________
Type of Offense (Circle One): Felony Misdemeanor
Location of Occurrence: ________________________________________________________
Date of Offense: __________________ Date of Sentencing: ______________________
Offense Type (DUI, Assault, Prostitution, etc.): ___________________________________________
Explanation/details surrounding the offense (attach additional sheets as necessary):
Sentencing Information: Please list the details of your sentencing (ie: probation, jail time, fines/costs, programs
Current Disposition: Please list the current disposition of your sentencing:
Don’t forget to attach certified documentation from the Clerk of Court pertaining to the arrest/charges,
sentencing due to the arrest and proof of successful completion of your sentencing.