DHMH - Maryland Board of Chiropractic Examiners
Massage Therapy Advisory Committee (MTAC)
4201 Patterson Avenue, Baltimore, MD 21 PHONE: , FAX:
Application for
Certification/Registration in Massage Therapy
General Information
Date of Any Previous Application: _____________ Date Application Submitted: __________________
ANSWER EACH SECTION COMPLETELY AND LEGIBLY
Applicant Name: ___________________________________________________________________________
First Middle Last
Applicant’s Name on School Transcript (if different from above): _____________________________________
Date of Birth: _______________________ Social Security #: ______________________________
(Note, there is no authority to require your disclosure of birth date or SSA #. However, you are advised that your failure
to provide this information will result in a substantial delay in processing your application or could result in the rejection
of your application due to the inability of the Board to adequately access your background, qualifications and identity).
Home Address: ___________________________________________________________________________
City: __________________________________ State: __________________ Zip: ____________________
Phone Number: _________________________ E-mail Address: ________________________________
Business Address: _________________________________________________________________________
City: ___________________________ State: ________________________ Zip: ______________________
Phone Number: ___________________________ E-mail Address:__________________________________
Preferred Mailing Address: Home ____________________ Business __________________________
(Note: This address will be the official mailing address maintained in your file. All official Board
mail will be sent to you at this address, including your certificate, registration and renewal forms).
Licensure/Certification and Legal Information
A. List all licenses, certificates and/or registrations held:
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Issuing Organization |
Date Issued |
License/Registration/Certificate # |
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B. Have you ever been denied a license, certificate, or registration? _____YES _____NO
If “YES”, explain reasons in detail: ________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
C. Have you ever had a license, certificate or registration revoked, suspended, canceled, or investigated?
_____YES _____NO
If “YES”, explain reasons in detail: ________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
D. Have you ever been arrested or pled guilty, no contest, nolo contendere or been convicted of a crime, received probation before judgment (other than a minor traffic violation) ______YES ______NO
If “YES”, provide the following information:
Charge of which convicted or to which you pled: ____________________________________________
Court that issued conviction or judgment: __________________________________________________
Date on which convicted: __________________ Sentence: ____________________________________
If convicted, you must also attach documentation and information:
* All documents pertaining to arrest, conviction, probation, parole
* Detailed statement of your education, social and rehabilitative activities since conviction
* Detailed list of all work activities and your supervisors since conviction
* List of all residences since conviction.
Professional Training
List all colleges, universities or trade schools attended to satisfy the academic requirements for massage certification/registration. List most recent first and provide official transcripts from any schools where you completed training in massage.
A. Name of School _____________________________________________________________________
School Address _____________________________________________________________________
Inclusive Dates Attended: From ________ To ________
Major Field Of Study: _________________________________________________________________
Degree Granted: ________________ Date: ___________
B. Name of School _____________________________________________________________________
School Address _____________________________________________________________________
Inclusive Dates Attended: From ________ To ________
Major Field Of Study: _________________________________________________________________
Degree Granted: ________________ Date: ___________
C. Name of School _____________________________________________________________________
School Address _____________________________________________________________________
Inclusive Dates Attended: From ________ To ________
Major Field Of Study: _________________________________________________________________
Degree Granted: ________________ Date: ___________
D. Name of School _____________________________________________________________________
School Address _____________________________________________________________________
Inclusive Dates Attended: From ________ To ________
Major Field Of Study: _________________________________________________________________
Degree Granted: ________________ Date: ___________
Your official college and/or massage school transcript(s) must be mailed directly to
DHMH - Board of Chiropractic Examiners
Massage Therapy Program
4201 Patterson Avenue
Baltimore, MD 21
Professional References
List below all references (minimum of 3) that can attest to your massage therapy skills, professional standards of practice and clinical work. These persons should work in the massage field or related professions such as chiropractic, medicine or physical therapy. You may use professors and instructors from your massage school.
A. Name of Reference: __________________________________________________________________
Business Name & Address: _____________________________________________________________
Business Phone: _____________________________________________________________________
Deg Degree Held: ________________________________ License/Cert/Registration Held: ______________
Professional Occupation: _______________________________________________________________
Will this reference be verifying all or some of your clinical experience? _____YES _______NO
B. Name of Reference: __________________________________________________________________
Business Name & Address: _____________________________________________________________
Business Phone: _____________________________________________________________________
Deg Degree Held: ________________________________ License/Cert/Registration Held: ______________
Professional Occupation: _______________________________________________________________
Will this reference be verifying all or some of your clinical experience? _____YES _______NO
C. Name of Reference: ___________________________________________________________________
Business Name & Address: _____________________________________________________________
Business Phone: _____________________________________________________________________
Deg Degree Held: ________________________________ License/Cert/Registration Held: ______________
Professional Occupation: _______________________________________________________________
Will this reference be verifying all or some of your clinical experience? _____YES _______NO
D. Name of Reference: __________________________________________________________________
Business Name & Address: _____________________________________________________________
Business Phone: _____________________________________________________________________
Deg Degree Held: ________________________________ License/Cert/Registration Held: ______________
Professional Occupation: _______________________________________________________________
Will this reference be verifying all or some of your clinical experience? _____YES _______NO
E. Name of Reference: __________________________________________________________________
Business Name & Address: _____________________________________________________________
Business Phone: _____________________________________________________________________
Deg Degree Held: ________________________________ License/Cert/Registration Held: ______________
Professional Occupation: _______________________________________________________________
Will this reference be verifying all or some of your clinical experience? _____YES _______NO
READ CAREFULLY AND SIGN IN PRESENCE OF NOTARY
I have read the Notices To Applicants. I acknowledge and understand their provisions. _____ (Initials)
In making this application to the Maryland State Board of Chiropractic Examiners, I agree to abide by all laws, rules and regulations of the Board of Chiropractic Examiners governing massage therapy found in Maryland Code Annotated, Health Occupations Article § 3-5A-01 et seq and in the Code of Maryland Regulations and to take all examinations necessary for the processing of my application. Upon issuance of a certificate or registration, I agree to be bound by the
Code of Ethics.
I have read the Massage Therapy statute and regulations. I acknowledge and agree that the burden is solely on me to produce all adequate and acceptable proof of educational, professional and character qualifications sufficient to meet the requirements for certification or registration.
I agree to hold the Board of Chiropractic Examiners, the Massage Therapy Advisory Committee, its members, officers, staff, agents and examiners free from any damage or claim for damage or complaints by reason of any action they or any one of them take in connection with this application, the examination attendant, the grades, with respect to any examination, and/or failure of the Board to issue me a certificate or registration. I hereby grant permission to the Board to seek any and all information or references it deems fit in securing my credentials pertinent to this application. I further agree that if issued a certificate or registration to practice massage therapy, upon suspension, revocation, or cancellation of such certificate or registration, I shall return it to the Board.
The information provided in this application is truthful and correct to the best of my knowledge and belief. I understand that providing false information of any kind or omitting information known to me may result in the voiding of this application. I agree that all documents and fees submitted with this application are the property of the Board and are non-refundable.
_______________________________________________ ___________________________
Applicant Signature Date
NOTARY ATTESTATION
The State of _________________________County of ____________________ BEFORE ME, the undersigned authority, on this
day, personally appeared (name of applicant) ___________________________________, known to me to be the person whose name is subscribed to the foregoing instrument, and having been by me first duly sworn on oath, acknowledged that he/she had executed the same for the purposes and considerations therein expressed and that the foregoing statements are true and correct.
GIVEN under my hand and seal of office, this ______________ day of _____________________, 20____________.
Notary Public in and for_________________________ County, _______________________________________, State ____________
(attach recent 2" x 2")
(photo in this area)
Signature of Notary_________________________________________
Printed or Typed Name of Notary ______________________________ Please place notary seal on edge of photograph
Name:______________________________________
APPLICATION CHECKLIST
Check off (√) the items included in the application packet.
_____ Completed application form for certification/registration.
____ Attached photos (TWO recent 2" x 2" - head & shoulders). One photo on Page 5 with
Notary Seal placed over edge of photo. The second photo can be attached to any
page of the application.
_____ Copy of Certificate or Official Candidate Score Report to verify passing the National
Certification Board for Therapeutic Massage and Bodywork (NCETMB) examination.
or National Certification Examination for Therapeutic Massage (NCETM).
For information: Call or visit the web site www.ncbtmb.com
OR
_____ Copy of National Certification Commission for Acupuncture & Oriental Medicine (NCCAOM) certificate or the Official Exam Score Report to verify passing the NCCAOM examination.
For information: Call or visit their web site www.nccaom.org
_____ Application fee of $100.00 by certified check or money order made payable to Maryland of Board of Chiropractic Examiners.
____ Jurisprudence examination registration form AND $ 50.00 fee by certified check or money order payable to the Maryland Board of Chiropractic Examiners.
To study for this examination, review the MD Massage Therapy laws and regulations.
_____ Copy of massage therapy school and/or college transcript(s).
_____ Have you requested that your official college/massage school transcript(s) be sent directly to the Board?
DHMH - Board of Chiropractic Examiners
Massage Therapy Program
4201 Patterson Avenue
Baltimore, MD 21
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If you attended a foreign school (outside of U.S.A.), are you willing to pay the fees to the contract commission, ICHP, to investigate, review and verify your school and transcripts (fees could range from $300 - $500)? If yes, you must contact the company on the attached sheet and follow their directions.
Your application will not be processed unless/until the board receives a report from the company. Also, you are advised that if an investigative review is conducted, this does not guarantee that your transcripts and application will be approved.
* * * * *
An application receipt letter will be mailed within 10 working days
after the application is submitted to the Board.
08/05DH
APPLICATION INSTRUCTIONS APPLICATION FOR CERTIFICATION BACK TO INDEX