Website: APPLICATION INSTRUCTIONS FOR MASSAGE LICENSE

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1 APPLICATION INSTRUCTIONS FOR MASSAGE LICENSE Please read the following instructions carefully before completing the application. Incomplete applications will cause delays in processing your application. If you have any questions about completing this application, please visit our website listed above and click the FAQs tab. MINIMUM REQUIREMENTS FOR QUALIFICATION 1. Did you complete / graduate from a massage therapy course of at least 500 hours? 2. Did you take and pass the National Exam (NCETM or NCETMB), or are you scheduled to take the National Exam and have a letter stating when you are taking it? If you answered YES to questions 1 and 2, then you may proceed. If you answered NO to any of the questions above, you are not qualified to be licensed by the Nevada State Board or practice in Nevada HOW TO FILL OUT THE APPLICATION ALL APPLICATIONS MUST INCLUDE THE FOLLOWING! 1. COMPLETELY fill out the application pages 3 through Sign and notarize Affidavit of Applicant by a notary (Page 7). 3. Payment Include a Money Order or Cashier s Check made payable to of Massage Therapists (NSBMT) for the appropriate amount. (Page 14) All fees are NON-REFUNDABLE. (DO NOT send a personal or business check) 4. Include 1 current passport sized photo. Original color photo ONLY on photo paper (No Exceptions!) No larger than 2 x 2 close up, front view of FACE no profile Taken within the last 60 days We will NOT ACCEPT the photo if you are wearing a hat, sunglasses, or anything obstructing your face. 5. A legible copy of your driver s license and a legible copy of your Social Security Card (Your Drivers License does not have to be issued from Nevada) If you do not have a driver s license, then submit a photo-copy of one of the following: i) State issued Identification card ii) Passport iii) Resident Alien Card 6. Temporary License (Page 9 and 10) Fill out page 9 and 10 ONLY if you have a supervisor. See temporary license section below for more information. (Optional) 7. Certified Statement from State Licensing Authority (Page 11) May be used if you are transferring from another jurisdiction. Please include a copy of your current massage license Posted 7/1/08 1

2 from the current jurisdiction NOTE: If you are sending in CSFSLA form (page 11) please do not submit fingerprint cards. 8. Include a copy of your NCBTMB certification or documentation showing successful completion of the National Exam for State Licensure (NESL), National Certification exam for Therapeutic Massage (NCETM) or the National Certification exam for Therapeutic Massage and Bodywork (NCETMB) i) If you have not yet taken the National Exam, but have received a letter from NCBTMB stating when you are scheduled to take the exam, please submit this letter. Once you have taken and passed the exam, you will need to send us your certificate or the letter that states you passed. 9. You may include a LEGIBLE copy of your school transcript if it is in the original sealed envelope or you will need to contact your school and have them send your official transcript(s) and certificate of completion directly to our office. We require that you completed a course of at least 500 hours If your school is no longer in business you will need to contact your state s Commission on Postsecondary Education. They should have copies of your transcript(s) which need to be mailed to us. To contact Nevada s Commission on Postsecondary Education call (702) FINGERPRINT CARDS Include 2 fingerprint cards. A State of Nevada and a FBI criminal history background investigation is required. Please go to your local law enforcement agency, or an agency that is authorized to perform fingerprinting. NOTE: See attached list of agencies that perform fingerprint services. Law enforcement agencies in other states may perform this service as well. The fingerprinting service or technician may charge you a separate fee to take your fingerprints. Also - If you are transferring from another jurisdiction you may include Certified Statement from State Licensing Authority in lieu of fingerprint cards. IN REVIEW 1. Make sure you have completely filled out the application. If any of the sections are incomplete, your application will be mailed back to you. 2. Please use the checklist at the end of this application to make sure you are not missing anything. 3. After you have sent your application into our office and find you need to make any changes (for example: address changes, phone numbers or references) please us or fax us your request. 4. Send your completed application to our Reno office. The processing time for an application for licensure is approximately 3 to 5 months. You will receive a postcard indicating your application has been received. We will contact you if we require further information. Posted 7/1/08 2

3 Massage Therapist Application Please type or print legibly all portions of this application. All of this application must be filled in so use N/A for items not applicable. Incomplete applications will not be processed. (Please check one) NEW APPLICATION TRANSFERRING FROM ANOTHER JURISDICTION Section 1 Personal Information Applicant Name Last First Middle Initial List all other names previously or currently being used by you Residence address (do not list Post Office boxes or mailbox drop addresses) Street City State Zip Previous address (if less than 1 year) Street City State Zip Mailing address (if different than the residence address) Street or PO Box City State Zip Social Security Number Date of Birth Place of Birth Home Phone Cell Phone Business Phone Gender Business Name: Male Female Business Address Street City State Zip Section 2 Child Support Information Please mark the appropriate response (failure to mark one of the three will result in denial of your application): I am NOT SUBJECT to a court order for the support of a child. I am SUBJECT to a court order for the support of one or more children and am in compliance with the order or am in compliance with a plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount pursuant to the order. I am SUBJECT to a court order for the support of one or more children and am NOT in compliance with the order or am NOT in compliance with a plan approved by the district attorney or other public agency enforcing the order for the repayment of the amount pursuant to the order. Posted 7/1/08 3

4 Section 3 Licensure Information Previous Licensure List all jurisdictions/states in which you have been licensed as a massage practitioner. Please attach another sheet of paper if you need more room. Sign off from Local jurisdiction to follow Please check here if you have never been licensed in any state jurisdiction. Jurisdiction/ State License Number Year Issued Expiration Date Section 4 Massage Training and Education Massage Training School sending transcripts date requested. School sent fingerprint cards prior to graduation. Please request official transcripts from the registrar of your school/(s) mailed directly to the Nevada State Board. Name of School City and State Years from and to Hours Completed Section 5 National Certification Board for Therapeutic Massage and Bodywork Exam Information NESL NCETM NCETMB Please provide a copy of your official certificate or confirmation letter. This must be provided in your application package only. (not from NCBMTB) Received test date confirmation letter included in package. Where taken Date Taken Expiration Date Posted 7/1/08 4

5 Section 6 Character References Please list the names with their complete and accurate addresses of five (5) natural persons who are not related to you, are not business associates and who are willing to serve as a character reference. Use additional sheet of paper if necessary. We will not be responsible for any delays attributed to the return of these letters by your references. Name Mailing Address Telephone Section 7 Application Screening Questions (use additional sheets of paper if needed) Yes No 1. Have you ever had any disciplinary proceedings instituted against you relating to your license to practice massage? If yes, complete the following: Date of Revocation/suspension/surrender/ or any other disciplinary action: Licensing Agency/jurisdiction that took action: Name and Address of Employer/supervisor: Reason for action: Yes No 2. Have you been arrested or convicted, within the 10 years immediately preceding submission of this application, of a felony or for any crime involving violence, prostitution or any other sexual offense? If yes, complete the following: Date of Charge/offense: Name and Address of Law Enforcement Agency: Charge: Disposition: Yes No 3. Are you currently a party to any pending litigation? If yes, please indicate whether you are a plaintiff or defendant and describe the nature of the litigation. (Please attach a separate sheet of paper) Posted 7/1/08 5

6 Yes Yes Yes Yes No No No No 4. Do you currently use chemical substances in any way which impairs or limits your ability to practice the full scope of massage? If yes, you must submit: a. A letter of explanation that addresses the impairment or limitations of practice b. A letter of reference from your current/last employer c. A copy of your last employment evaluation d. If you are using the chemical substance as a confirmed medical necessity, a letter from your treating practitioner documenting the diagnosis and medical necessity for the use of chemical substances, including any practice limitations. 5. Are you currently in recovery for chemical dependency, chemical abuse or addiction? If yes, you must submit: a. A letter of explanation describing your recovery experience, including length of continuous recovery, treatment, and current recovery activities b. Documentation from knowledgeable individual(s) documenting your length of sobriety c. Documentation of inpatient or outpatient chemical dependency treatment. 6. Do you currently have a medical or psychiatric/mental health condition which in any way impairs or limits your ability to practice the full scope of massage? If yes, you must submit: a. A letter of explanation regarding your condition, whether temporary or permanent, including diagnosis, past hospitalizations, date of last treatment, current treatment plan, and how your condition my interfere with your ability to practice the full scope of massage safely b. Documentation from treating practitioner regarding the diagnosis, (Axis I-V for psychiatric diagnosis), medications, current status and treatment plan, the extent of condition, and statement regarding your ability to carry out massage duties reliably and with good judgment. 7. Have you committed any of the offenses as outlined below and in NRS 640C.700: IF YES, Please explain on a separate piece of paper. NRS 640C.700 Grounds for disciplinary action. The Board may refuse to issue a license to an applicant, or may initiate disciplinary action against a holder of a license, if the applicant or holder of the license: 1. Has submitted false, fraudulent or misleading information to the Board or any agency of this State, any other state, a territory or possession of the United States, the District of Columbia or the Federal Government; 2. Has violated any provision of this chapter or any regulation adopted pursuant thereto; 3. Has been convicted of a crime involving violence, prostitution or any other sexual offense, a crime involving any type of larceny, a crime relating to a controlled substance, a crime involving any federal or state law or regulation relating to massage therapy or a substantially similar business, or a crime involving moral turpitude within the immediately preceding 10 years. 4. Has engaged in or solicited sexual activity during the course of practicing massage on a person, with or without the consent of the person, including, without limitation, if the applicant or holder of the license: (a) Made sexual advances toward the person; (b) Requested sexual favors from the person; or (c) Massaged, touched or applied any instrument to the breasts of the person, unless the person has signed a written consent form provided by the Board; 5. Has habitually abused alcohol or is addicted to a controlled substance; 6. Is, in the judgment of the Board, guilty of gross negligence in his practice of massage therapy; 7. Is, determined by the Board to be professionally incompetent to engage in the practice of massage therapy; 8. Has failed to provide information requested by the Board within 60 days after he received the request; 9. Has, in the judgment of the Board, engaged in unethical or unprofessional conduct as it relates to the practice of massage therapy; 10. Has been disciplined in another state, a territory or possession of the United States or the District of Columbia for conduct that would be a violation of the provisions of this chapter or any regulations adopted pursuant thereto if the conduct were committed in this State; 11. Has solicited or received compensation for services relating to the practice of massage therapy that he did not provide; 12. If the holder of the license is on probation, has violated the terms of his probation; or 13. Has engaged in false, deceptive or misleading advertising, including, without limitation, falsely, deceptively or misleadingly advertising that he has received training in a specialty technique of massage for which he has not received training, practicing massage therapy under an assumed name and impersonating a licensed massage therapist. Posted 7/1/08 6

7 Affidavit of Applicant / Authorization of Release I,, certify that I am the person described and identified in this application; I have answered all the questions truthfully and completely, and any documents that I have provided in support of my application are, to the best of my knowledge, accurate. I certify that I have not had any undisclosed disciplinary proceedings instituted against me relating to my license to practice massage and I have disclosed or have not been arrested or convicted, within the 10 years immediately preceding submission of this application, for any crime involving violence, prostitution or any other sexual offense. I authorize all institutions or organizations, including educational institutions and organizations, my references, employers (past and present), business and professional associations (past and present) and all governmental agencies and municipalities (local, state, federal and foreign) to release to the Nevada Sate Board any information, files or records required by the Nevada State Board in connection with processing this application. I understand that furnishing false or misleading information or failing to furnish required information on this application may be cause for the denial, suspension or revocation of my license to practice Massage Therapy in the State of Nevada. Signature of Applicant: Date: State of County of Signed and sworn to before me this day of 20 by, who personally appeared before me. Notary Public Signature Notary commission expiration date (Official Stamp) Posted 7/1/08 7

8 Application Checklist All sections on pages 3 to 6 completed Full and complete addresses of your references in Section 6 Section 7 is marked appropriately Affidavit on page 7 notarized by a notary Legible copy of a state issued I.D. (i.e. driver s license) and Social Security Card or resident alien card which makes you eligible to work in the United States, if applicable. Make sure you include a copy of the renewal on the back if the date on the front of your driver s license has expired Copy of your NCETMB, NCETM or NESL certificate or any documentation showing that you have taken and passed the National Exam Appropriate fees are included in the form of money order or cashiers check made payable to or NSBMT 1 passport sized photo (in color) 2 fingerprint cards (make sure your personal information is filled out on the card and signed). Include a copy of current jurisdiction massage license. Make sure you contact your school to have them directly send us a copy of your official transcript(s) Mail your completed application to our Reno office. Once again, any incomplete applications will be returned. Posted 7/1/08 8

9 Temporary License Application Part One The temporary license application allows you the ability to work while awaiting the results of the criminal history background investigation and/or the exam. To qualify for a temporary license you will have to: a) complete the main licensing application b) scheduled to take or have taken the national exam c) provide fingerprint cards to the board for a criminal history background check, or were able to complete page 11 in application packet A temporary license is valid for 90 days and is released to you 45 days from the date we receive a you application. If you submit the temporary license application after your main application, we start counting the 45 days from the date we receive your temporary license application. A temporary license will not be issued if you have any criminal history charges that need to be reviewed before The Board. During this period you can ONLY work under the supervision of your approved supervisor only licensed by the. If that person is not present in the business, you may not work. Only one temporary license is issued, so you may NOT change your supervising massage therapist. No exceptions. Outcall is not permitted. No extensions of this license can or will be granted. All other documents in this packet must be in order before the board will review your application for a temporary license. The applicant must be supervised by a licensed massage therapist at all times. I, request the Board to issue a temporary license while I am awaiting the results of the exam and the criminal history background investigation. Name of applicant Mailing address City State: Zip: Contact Phone # I understand that I can only work while my supervisor is present. Date: Applicant Signature Posted 7/1/08 9

10 Temporary License Application Part two This section must be completed by the supervising massage therapist for the temp license: Name: Address: City: State: Zip: Telephone: Home: Cellular/ Other Business Name: Business Address: City: State: Zip: Telephone: Nevada State License Number: NVMT. I, certify that I am the duly licensed massage therapist in Nevada who will be supervising the applicant at my place of business for a period not to exceed ninety (90) days. I understand that I will notify the Board of any changes to the terms of this agreement. Signature of supervising massage therapist: Date: THERAPISTS PLEASE NOTE: OUTCALL SERVICE IS NOT PREMITTED ON A TEMPORARY LICENSE Posted 7/1/08 10

11 Dear Sirs, Certified Statement from State Licensing Authority TO BE COMPLETED BY LICENSING AUTHORITY ONLY (Transferring from another jurisdiction) The applicant listed herein has applied to the for a license for Massage Therapy. In order to complete this application, we request that you complete the following and mail to the Nevada State Board at the address listed above. Your assistance in this matter is greatly appreciated. Lisa Cooper, Executive Director, Applicant Name: License Number: This certified statement issued by the licensing authority in each state/territory or possession of the United States or the District of Columbia in which the applicant is or has been licensed to practice massage therapy during the immediately preceding 10 years verifying that: (please circle appropriate response) The applicant has / has not been involved in any disciplinary action relating to their license; and Disciplinary proceedings relating to this license to practice massage therapy are / are not pending. Case Number: Jurisdiction: To be completed by the State Licensing authority in the State(s) where you are currently or have been licensed: Date: Name of licensing agency/jurisdiction: Address: State, Zip: Phone: Fax: Signature: Date: Title: Please print agent s name: (Official Stamp) Posted 7/1/08 11

12 Instructions for Completion of Fingerprint Cards 1. All new applicants must complete two fingerprint cards 2. It often takes several months for the Nevada Department of Public Safety and the FBI to process the fingerprint cards PLAN AHEAD! 3. Complete all requested information blocks on both cards. Make sure these areas are completed and legible: Last, first, and middle names, signatures, residence (complete Address); citizenship; date of birth; place of birth; sex; race; height; weight; eyes; hair; and social security number. Cards without all information blocks completed are considered incomplete and will be returned to the applicant. Illegible cards will not be processed. 4. Law enforcement agencies (highway patrol, police, sheriff) in all 50 states can place your fingerprints on the cards and complete the remaining required information. Fingerprinting may also be done by a medical facility that has the appropriate equipment and staff trained/certified by the State of Nevada Records and Identification Services. 5. Make Certain: a. Both fingerprint cards are completed with legible fingerprints b. Descriptive information is complete and legible c. Both cards are signed by the appropriate persons (applicant and official) d. Include the fingerprint cards with your completed application that is mailed to the Board with appropriate fees. Please Note: fingerprint results are valid for only six months. NOTICE: It may take several months for the Board to receive the official fingerprint results from the Department of Public Safety and FBI. If you are eligible for a temporary license, it will only be valid for three months from the date of issuance. Partial list of Fingerprinting Sites The does not endorse or recommend any organization on this list. (It is intended for informational use only) - CLARK COUNTY Henderson Henderson Police Department 223 Lead St Henderson, NV Phone Mesquite Mesquite Police Department 500 Hillside Drive Mesquite, NV Phone: WASHOE COUNTY - Reno Police Department 455 East Second St Reno, NV Phone: North Las Vegas North Las Vegas Police Department 1301 E Lake Mead Blvd North Las Vegas, NV Phone: Las Vegas Las Vegas Metro PD Fingerprint Bureau 5880 Cameron Street Las Vegas, NV Phone: Sparks Police Department 1701 Prater Way Sparks, NV Phone: Washoe County Sheriffs Office 911 Parr Blvd Reno, NV Posted 7/1/08 12

13 - ALL OTHER COUNTIES - Carson City Churchill County Carson City Sheriffs Office 901 East Musser St Carson City, NV Phone: Fallon Police Department 55 West Williams Ave Fallon, NV Phone: Churchill Co Sheriffs Office 73 N Maine St Fallon, NV Phone: Douglas County Elko County Douglas County Sheriffs Office 1625 Eighth St Minden, NV Phone: Elko County Sheriffs Office 775 West Silver St Elko, NV Phone: Elko Police Department 1401 College Ave Elko, NV Phone: Eureka County Esmeralda County West Wendover Police Dept 801 Florence Way West Wendover, NV Phone: Eureka Co Sheriffs Office 411 N. Main St Eureka, NV Phone: Esmeralda Co. Sheriffs Office Courthouse, 233 Crook St Goldfield, NV Phone: Humboldt County Lander County Lincoln County Humboldt Do. Sheriffs Office Administrative Offices 25 W Fifth Street Winnemucca, NV Lander Co. Sheriffs Office State Route 305 #2 Battle Mountain, NV Phone: Lincoln Co. Sheriffs Office County Courthouse Pioche, NV Phone: Phone: Lyon County Mineral County Lyon County Sheriffs Office 30 Nevin Way Yerington, NV Phone: Nye County Tonopah 101 Radar Road Tonopah, NV Phone: Pershing County Pershing Co. Sheriffs Office 395 Ninth St Lovelock, NV Phone: White Pine County White Pine Co. Sheriffs Office 1785 Great Basin Blvd Ely, NV Phone: Yerington Police Dept 30 Nevin Way Yerington, NV Phone: Beatty 426 C Avenue South Beatty, NV Phone: Storey County Storey Co. Sheriffs Office 911 Highway 341 South Virginia City, NV Phone: Other States Any Law enforcement agency is able to provide this service In addition there may be private companies that provide official fingerprinting service. Mineral Co. Sheriff 105 South A Street Hawthorne, NV Phone: Pahrump 1520 East Basin Road Pahrump, NV Phone: Posted 7/1/08 13

14 Please type or print legibly all portions of this application. Massage Therapist Application Fees Background Investigation New license must include Transfer License may use page 10 $ $ Application Fee $ $ License Fee $ $ Application for Temporary License Optional $ $ Temporary License Optional $50.00 $ TOTAL AMOUNT ENCLOSED $ All fees are non-refundable. Personal or business checks will not be accepted Helpful Hint Temp Application with Temp License, Application with License fee, background fee $ Application with License fee, background fee $ Application with License fee and Sending in Certified Statement from State Licensing Authority $ Posted 7/1/08 14