I,________________________ submit that my official mailing address is changed to:


______________________________       _________________________           ___________                          Street                                                                 City/State                                            Zip                         

The address change was/is effective on:___________________________

_________________________________                               __________________________                 
                 Signature                                                                                     Date

Send to:  Emily Jones
   Massage Therapy Program
   4201 Patterson Avenue
   Balto., MD 21

Don't delay receiving your renewal application because you haven't reported your current address to the Board.