Free 53748.FH11 - Indiana

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APPLICATION FOR CERTIFICATION AS A MASSAGE THERAPIST
State Form 53748 (R / 3-09) Approved by State Board of Accounts, 2009

INSTRUCTIONS:

Please print clearly in ink.

STATE BOARD OF MASSAGE THERAPY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2051 E-mail: [email protected] www.pla.IN.gov

*Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is mandatory, and this record cannot be processed without it.

FOR OFFICE USE ONLY APPLICATION FEE DATE FEE PAID (month, day, year) RECEIPT NUMBER CERTIFICATE NUMBER ISSUED DATE CERTIFICATE ISSUED (month, day, year)

APPLICANT Attach one (1) passport type quality photograph of yourself taken within the last eight weeks.

DO NOT WRITE ABOVE THIS LINE

APPLICANT INFORMATION
Name (last, first, middle, maiden or previous) Address (number and street or rural route, city, state, and ZIP code) Date of birth (month, day, year) Work telephone number Place of birth Home telephone number E-mail address Social Security number *

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METHOD OF OBTAINING CERTIFICATION Please check one. I am applying for certification by examination. I am applying for certification by endorsement. I have an active license or certificate to practice massage therapy in another state.

EDUCATION INFORMATION
Have you graduated from high school or obtained a GED?

Yes
Name of school Location (city and state)

No

If yes, please provide the information below.
Date of diploma / GED (month, day, year)

MASSAGE THERAPY PROGRAM INFORMATION APPLICANTS MUST ATTACH AN ORIGINAL OR NOTARIZED COPY OF TRANSCRIPTS OR CERTIFICATE OF COURSE COMPLETION.
Name of course provider Location (city and state) Date started (month, day, year) Date completed (month, day, year)

Number of credit hours completed

EXAMINATION INFORMATION
I have passed the (check one):

MBLEX

NCETM

NCBTMB

NBCA NCE

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OTHER STATE LICENSURE / CERTIFICATION / REGISTRATION / PERMIT
Do you now hold, or have you ever held, a license / certificate / registration / permit to practice or perform any regulated profession by a state licensing board?

Yes

No

If yes, list all states below, including Indiana, in which you have held license / certification / registration / permit to practice any state regulated profession. TYPE OF LICENSE / CERTIFICATE / REGISTRATION / PERMIT STATE LICENSE NUMBER DATE ISSUED CURRENT STATUS

QUESTIONS If your answer is "yes" to any of the following, explain fully in a signed and notarized statement, including all related details. Include the violation, location, date, disposition. Letters from attorneys are not accepted in lieu of your statement. Falsification of any of the following is grounds for permanent revocation of a certificate issued pursuant to this application. 1. Has disciplinary action ever been taken regarding any health license, certificate, registration or permit you hold or have held? 2. Have you ever been denied a license, certificate, registration or permit to practice or perform any regulated occupation in any state (including Indiana) or country? 3. Have you ever been convicted of, pled guilty or nolo contendre to any offense, misdemeanor or felony in any state? (except for minor violations of traffic laws resulting in fines) 4. Are you currently, or have you ever been, listed on a national or state registry of sex offenders? 5. Have you ever been charged with or convicted of prostitution, rape, or any other sexual misconduct? Yes Yes Yes Yes Yes No No No No No

APPLICATION AFFIRMATION I hereby swear or affirm under the penalties of perjury, that the statements made in this application are true, complete and correct.
Signature of applicant Date signed (month, day, year)

AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize, request and direct any person, firm, officer, corporation, association, organization or institution to release to the Professional Licensing Agency or the State Board of Massage Therapy, any files, documents, records or other information pertaining to the undersigned, requested by the Agency, the Board or any of its authorized representatives in connection with processing my application for certification. I hereby release the aforementioned persons, firms, officers, corporations, associations, organizations and institutions from any liability with regard to such inspection or furnishing of any such information. I further authorize the Professional Licensing Agency or the State Massage Therapy Board, to disclose to the aforementioned persons, firms, officers, corporations, associations, organizations, and institutions any information which is material to my application, and I hereby specifically release the Agency and the Board from any and all liability in connection with such disclosures. A photostatic copy of this authorization has the same force and effect as the original.

AFFIRMATION I hereby swear or affirm that I have read the above statements and agree to same.
Signature of applicant Date signed (month, day, year)

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