Massage License Texas Lookup – Fill Out and Use

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)

State of ___________________________________________.
This certifies that ____________________________________ is:
	(Applicant’s Name)
Registered [ ]	Certified [ ]		Licensed [ ] as a ___________________________________________
Current status of this license/license/certification is:
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:

[	]	Education Requirements	[	]	Endorsement/Reciprocity
[	]	State Examination	[	]	Grandfather Requirements
[	]	National Examination

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 ________

d.	Written examination required? Yes [	]	No	[	]
e.	Practical examination required? Yes [	]	No	[	]

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)

DSHS Publication # F64-10701 Massage Therapy Application Revised 5/09