MASSAGE THERAPY LICENSING PROGRAM
TEXAS DEPARTMENT OF STATE HEALTH SERVICES
P.O. Box 149347, Mail Code 1982
Austin, Texas 78714-9347
OUT OF STATE LICENSE VERIFICATION
The application for licensure as a Massage Therapist in the State of Texas requires this form to be completed by all State Boards where I hold or have ever held a license. My signature below is your authorization to release all information in your files, favorable or otherwise, regarding myself. Section I to be completed by applicant. Please type or print
clearly.
Applicant Name ___________________________________________ License Number __________________
Applicant’s Signature _______________________________________ Date ___________________________
Address __________________________________________________________________________________
P O Box or Street No. CityState Zip
Telephone Number (include area code) ______________________________ Date of Birth ________________
Section II. (Completed by out-of-state licensing authority)
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State of ___________________________________________. |
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This certifies that ____________________________________ is: |
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(Applicant’s Name) |
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Registered [ ] |
Certified [ ] |
Licensed [ ] as a ___________________________________________ |
Current status of this license/license/certification is: |
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Active [ ] |
Lapsed [ ] |
Inactive [ ] |
Denied ** [ ] |
Suspended** [ ] |
Revoked** [ ] |
Effective date of License/Registration/Certification________________________________________________
**Please attach a copy of the Findings of Fact and Decision and Order. License/Registration/Certification issued based on:
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Education Requirements |
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Endorsement/Reciprocity |
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State Examination |
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Grandfather Requirements |
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National Examination |
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Qualifications for licensure in this state are:
a.Total hours of education ________
b.Number of hours required in Swedish Massage ________
c.Number of hours required in Anatomy & physiology ________
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Written examination required? Yes [ |
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No |
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Practical examination required? Yes [ |
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No |
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Please attach a copy of the current massage therapy requirements (rules) for your state. (If current rules have been sent to this office within the last 12 months, please disregard this request.)
I certify that the above information is correct and true. I have enclosed a copy of the requirements for this state. Name of Agency __________________________________ Address _________________________________
Signature ___________________________________ Typed Name __________________________
Title _______________________________________ Date ________________________________
(STATE SEAL)
