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1 NEW MEXICO MASSAGE THERAPY BOARD 2550 CERRILLOS ROAD, SANTA FE, NM P. O. BOX 25101, SANTA FE, NM PHONE: (505) ; FAX: (505) Website: APPLICATION FOR REGISTERED MASSAGE THERAPY INSTRUCTOR (This Form is Effective 6/24/2005 and must be used by persons applying after 6/23/05) At the time of application, applicants for Registered Massage Therapy Instructor (RMTI): 1. Must meet the requirements outlined in Part 6 ( NMAC) of the massage therapy rules, which are available online in the Rules and Law link at or are included in the application packet if received directly from the Board office. 2. Must hold a valid New Mexico massage therapist license; 3. Must have practiced massage therapy for a minimum of two years during the three years immediately preceding application for a massage therapy instructor (MTI) registration; and 4. Must complete the RMTI application process in accordance with Board regulations, policies, and procedures. 5. All RMTI applicants must complete all sections of this form unless specifically stated otherwise on the form (i.e. schoolbased or independent ). Please check only one category of registration for which you are applying. SCHOOLBASED INSTRUCTOR: You will be teaching at a New Mexico registered massage therapy school. INDEPENDENT INSTRUCTOR: You will be teaching outside of a New Mexico registered massage therapy school. (Form A for Massage Therapy Instructor must accompany your application.) This application must be legible; either printed in black ink or typed and must be mailed to the Board office (faxed application and/or supporting documentation will not be accepted. : SECTION A GENERAL APPLICANT INFORMATION NAME LAST (as licensed with the Board) FIRST MIDDLE INITIAL MAILING ADDRESS. & Street/P. O. Box (check here if this is a change of address) CITY: STATE: ZIP CODE DATE OF BIRTH BUSINESS OR MESSAGE PHONE ( ) HOME MESSAGE PHONE ( ) SOCIAL SECURITY. DATE LICENSED IN NEW MEXICO AS A MASSAGE THERAPIST NM MT LICENSE NO. EMPLOYER: EMPLOYER ADDRESS: ADDRESS: Answers to the Most Frequently Asked Questions Regarding RMTI s Every registered instructor teaching massage for continuing education purposes must be Attach one (1) 2"X2" registered as an independent massage therapy instructor ( A. NMAC). photograph of head and The Independent RMTI may provide instruction at a registered massage therapy school without shoulders only, taken within the last six (6) having to obtain a schoolbased MTI registration, provided the instruction is limited to the school s months curriculum approved by the Board ( B. NMAC). The Independent RMTI must submit a curriculum, including continuing education (CE) courses, for board review and approval ( C. NMAC). PLEASE STAPLE The Independent RMTI must provide attendees with certificates of attendance at CE s that include Do not tape the name of the course, the date(s) of training, the number of class hours completed, the name, or glue registration number, and address of the Independent RMTI; and the signature of the independent RMTI ( D NMAC). Registered schoolbased instructors may only provide instruction within the Boardapproved curriculum of a registered massage therapy school ( B NMAC). Revised:

2 SECTION B INSTRUCTIONAL EXPERIENCE OF PROFESSIONAL TEACHING/WORKSHOP Completion of a minimum of 50 contact hours of instructional experience of professional teaching, or workshop instruction is required. List the instruction and attach supporting documentation verifying the information provided below. NAME OF SCHOOL/PROFESSIONAL LOCATION WHERE THE TRAINING WAS PROVIDED MAILING ADDRESS. & Street/P. O. Box PHONE ( ) NAME OF PERSON WHO CAN VERIFY THE TRANING YOU PROVIDED TITLE SECTION C PROFESSIONAL MASSAGE THERAPY EXPERIENCE Professional Massage Therapy Experience shall be limited to lawful professional Massage Therapy experience for compensation. Documented experience must verify two (2) years of professional massage therapy experience within the last three (3) years prior to application. Mark the boxes with an X, to indicate the methods by which you will document lawful professional massage therapy experience, which must include a minimum of three (3) different forms of documentation, and attach copies of the documentation marked. Income tax forms documenting massage therapy practice Verifiable letters from clients confirming receipt of massage therapy services from the applicant (must include names, addresses, phone numbers, etc.) Yellow pages advertisement(s) that show dates of the ad publication Printed flyers or brochure advertisements with dates Proof of rent or lease of practice location or office space used for massage therapy practice Proof of current professional association membership Proof of current professional insurance Copies of dated receipts for massage therapy practicerelated supplies or furnishings that total a minimum of $500 Verifiable letters from employers (must have names, addresses, phone numbers, etc.) Work log consisting of client s names, addresses, and/or phone numbers, appointment dates, and time periods worked on clients SECTION D (REQUIRED ONLY IF YOU ARE APPLYING AS AN INDEPENDENT INSTRUCTOR ) NAME OF BUSINESS (this is where students/licensees will receive massage therapy instruction) MAILING ADDRESS. & Street/P. O. Box PHYSICAL ADDRESS. & Street/P. O. Box Revised:

3 SECTION E MASSAGE THERAPY EDUCATION (REQUIRED ONLY IF YOU ARE APPLYING AS AN INDEPENDENT INSTRUCTOR ) You must list and attach documentation supporting the Massage Therapy training that you have received related to the curriculum, Form A for Massage Therapy Instructors, that you are applying for approval to teach. NAME MASSAGE THERAPY PROGRAM MAILING ADDRESS. & Street/P. O. Box COURSE TITLE HOURS OCMPLETED DATE OF COMPLETION NAME MASSAGE THERAPY PROGRAM MAILING ADDRESS. & Street/P. O. Box COURSE TITLE HOURS OCMPLETED DATE OF COMPLETION NAME MASSAGE THERAPY PROGRAM MAILING ADDRESS. & Street/P. O. Box COURSE TITLE HOURS OCMPLETED DATE OF COMPLETION SECTION F SCHOOL S ATTESTATION (REQUIRED ONLY IF YOU ARE APPLYING AS A SCHOOLBASED INSTRUCTOR ) This section is to be completed by the SCHOOL at which the applicant will be practicing. This is to certify that, upon approval and issuance of a Massage Therapy Instructor Registration, the applicant named in this application will be teaching at our New Mexico Registered Massage Therapy School, and teaching within the curriculum submitted to and approved by the New Mexico Massage Therapy Board by the school. On behalf of our school, I agree to notify the New Mexico Massage Therapy Board, in writing, when the Instructor is no longer teaching at our school. NAME OF SCHOOL PRINT NAME SCHOOL REPRESENTATIVE PHONE ( ) TITLE SIGNATURE (Sign before a tary Public) State of County of DATE / / Before me on this day of, 2, personally appeared the above named School Representative who being by me duly sworn upon oath says that he/she is authorized to certify and agree to the terms outlined in this section. tary: Commission Expiration Date: / / (SEAL) Revised:

4 THE APPLICATION REVIEW PROCESS AVERAGES APPROXIMATELY TWO (2) TO FOUR (4) WEEKS. THEREFORE, IF YOU DO NOT RECEIVE A STATUS LETTER AFTER FOUR (4) WEEKS, YOU MAY CONTACT THE BOARD OFFICE TO FOLLOWUP ON THE STATUS. IF THIS APPLICATION IS STILL INCOMPLETE ONE (1) YEAR AFTER RECEIPT BY THE BOARD OFFICE, THE APPLICATION AND SUPPORTING DOCUMENTATION WILL BE DEEMED WITHDRAWN AND THE FEES WILL BE FORFIETED. SECTION G APPLICANT ANSWER ALL OF THE FOLLOWING QUESTIONS 1. Have you been convicted of an offense punishable by incarceration in a state penitentiary or federal prison? 2. Have you ever been denied a license/registration or permission to practice/teach massage therapy or have you been denied permission to take an examination to practice/teach massage therapy in any state, country or territory? 3. Has any disciplinary action ever been taken regarding your practice/teaching of massage therapy or any license/registration you hold or have held to practice/teach massage therapy? (Disciplinary actions include, but are not limited to, suspension, probation, practice limitation, reprimand, letters of admonition, censure, etc.). 4. Are there any allegations/investigations currently pending against your license or registration that you are aware of? 5. Have you ever been a defendant in a legal action involving professional liability (malpractice); or had a professional liability claim paid in your behalf; or have you paid such a claim yourself? 6. Are you currently more than thirty (30) days in arrears in payment of courtordered child support payments either in New Mexico or any other state or jurisdiction? FOR ANY YES ANSWER TO THE QUESTIONS IN SECTION G, PROVIDE DETAILS INCLUDING THE OUTCOME ON A SEPARATE COVER, AND ATTACH SUPPORTING DOCUMENTATION INCLUDING, BUT NOT LIMITED TO: 1. Certified copies of the legal documents, certified by the Clerk entering the conviction; 2. Character reference letters from family, friends, colleagues, employer, etc., to include their addresses and phone numbers, which must be originals addressed to the Board and which must be dated within one (1) month from the date this application is signed and submitted to the Board; 3. If you are still on probation, a letter from your Probation Officer outlining the status, which must be original and addressed to the Board and which must be dated within one (1) month from the date this application is signed and submitted to the Board; 4. For question #3, documentation outlining the basis, outcome, and status must be sent directly to this office from the licensing Board(s); 5. For question #4, a copy of the complaint notification received by the applicant and the status of the complaint/investigation. 6. For question #5, a certified statement from HSD stating that you are in compliance with the judgment and order for support; and 7. Any other documentation regarding the matter. OTHER CONDITIONS: As a condition for licensure for any person who has received a conviction involving drugs, the applicant must provide and affidavit with this application that he/she authorizes the Board to require that a urinalysis to be conducted at the applicant s expense, and that the urinalysis results will be forwarded directly to the Board by the laboratory. A YES answer does not necessarily disqualify an applicant from licensure, however the Board may require additional information and/or clarification, therefore it is important that you provide complete and succinct information. Each case is considered on its own merit. If you are applying for a temporary license and you answered, YES to any question above the application will have to be presented to the Board for approval/disapproval before a temporary license may be issued. Revised:

5 All requested information is essential and must be provided. Failure to present a completed application by omitting information sought, having less than a full and complete disclosure, or failure to have the required documentation provided as required in this application, will result in delay or cause return of the application. The Board shall neither approve nor deny an application until it is received in proper form, contains the information required by law and as requested by this application. The responsibility for completing the application is solely that of the applicant. The burden of proof in satisfying the Board that you are entitled to a registration to teach massage therapy is upon you. THE BOARD DOES NOT HAVE THE AUTHORITY TO GRANT A WAIVER OF ANY REQUIREMENT. SECTION H APPLICANT S ATTESTATION I acknowledge receiving and reading the Massage Therapy Rules and Regulations (16.7 NMAC) and the Massage Therapy Board s statute, presently administered by the New Mexico Massage Therapy Board and represent and agree that should I be granted the registration applied for I shall at all times obey the aforementioned Rules/Parts & Statute. Under penalties of perjury, I declare and affirm that the statements made in the foregoing application, including attached documentation, are true, complete and correct. I understand that any false or misleading information in or in connection with, my application may be cause for denial or loss of registration. If Applying As A SchoolBased Instructor: This is to certify that, upon approval and issuance of a Massage Therapy Instructor Registration, I will teach at the New Mexico Massage Therapy School named in this application, and teach within the school s curriculum submitted to and approved by the New Mexico Massage Therapy Board. I agree to notify the New Mexico Massage Therapy Board, in writing, when I am no longer teaching at the school. If Applying As An Independent Instructor: This is to certify that, upon approval and issuance of a Massage Therapy Instructor Registration, I will teach within the curriculum/course outline submitted to and approved by the New Mexico Massage Therapy Board. I agree to notify the New Mexico Massage Therapy Board, in writing, when I am no longer teaching. SIGNATURE (Sign before a tary Public) State of County of DATE / / FOR NOTARY: The foregoing document was executed, subscribed, and sworn to before me this day of, 2. tary Name (Printed): tary Name (Signature): Commission Expiration Date: / / (NOTARY SEAL) The following information requested here is voluntary, as it may be useful in obtaining funding and grants. Your consideration is appreciated. GENDER Male Female ETHNIC INFORMATION Asian/Pacific Islander Hispanic Black American Indian Caucasian nhispanic COUNTRY CITIZENSHIP Revised:

6 MASSAGE THERAPY INSTRUCTOR REGISTRATION SCHOOLBASED INSTRUCTOR REGISTRATION CHECKLIST SchoolBased Instructor Applicant must complete and return this checklist with the application for registration. It is your responsibility to ensure that the requested documentation is provided to the Massage Therapy Board. Failure to complete correctly and/or return this checklist with your application along with the required fee and documentation will cause a delay processing your application. * NA For Office Use Only Date Received Complete Application for Massage Therapy Instructor Registration, which is signed before a notary Attached & public and includes a 2 x2 photograph of applicant. (Photocopy or scanned photograph is not / / acceptable.) Enclosed Enclosed Application Fee of $50.00, payment made out to: Massage Therapy Board / / *If, date that is will be provided to the Board Office: / / A minimum of three (3) different forms of documentation supporting Massage Therapy experience as outlined in Section B of the Massage Therapy Instructor application: Income tax forms documenting massage therapy practice Verifiable letters from clients confirming receipt of massage therapy services from the applicant (must include names, addresses, phone numbers, etc.) Yellow pages advertisement(s) that show dates of the ad publication Printed flyers or brochure advertisements with dates Proof of rent or lease of practice location or office space used for massage therapy practice Proof of current professional association membership Proof of current professional insurance Copies of dated receipts for massage therapy practicerelated supplies or furnishings that total a minimum of $500 Verifiable letters from employers (must have names, addresses, phone numbers, etc.) Work log consisting of client s names, addresses, and/or phone numbers, appointment dates, and time periods worked on clients *If NO (not enclosed) please note the date that this documentation will be provided to the Board Office: / / Documentation verifying completion of a minimum of 50 contact hours of instructional experience of professional teaching or workshop instruction. / / / / *If NO (not enclosed) please note the date that this documentation will be provided to the Board Office: / /_ FOR OFFICE USE ONLY Application Deemed Complete Date of Completion / / Copy of Checklist Mailed to Applicant / /, / / / /, / /, / / Board Staff tes: L2000 Database Entry / / LMT LICENSE # STATUS: Date Completed: / / Registration # Issue Date / / Expiration Date: / / SchoolBased Instructor Applicant: Return this completed checklist with your application for massage therapy instructor registration. Revised:

7 The SchoolBased Instructor applicant must complete and submit this section with the application. All boxes must be checked confirming that you are aware of the following. I understand that the application review process is averaging approximately two (2) to four (4) weeks after receipt by the Board office. It is my responsibility to prove that I meet the minimum requirements for massage therapy instructor registration The Board cannot waive any of the requirements for registration I must hold a current New Mexico massage Therapy license I must have a minimum of two (2) years of professional massage therapy experience within the last three (3) years prior to application I must have completed a minimum of 50 contact hours of professional teaching/workshop instruction As a registered SchoolBased instructor, I will only be authorized to provide massage therapy instruction at New Mexico registered massage therapy schools and teach only within the school curriculum approved by the New Mexico Massage Therapy Board All fees paid to the Massage Therapy Board are nonrefundable, even if I withdraw my application for registration I am not to provide massage therapy instruction until I receive a massage therapy instructor registration issued by the New Mexico Massage Therapy Board Renewal notices are sent out as a courtesy reminder, it is my responsibility to contact the Board and to renew my license if I do not receive a renewal application Failure to renew my license as a massage therapist will automatically result in my massage therapy instructor registration being placed on inactive status I must notify the Board office in writing of any changes (name change, address change, etc.) applicable to my massage therapy instructor registration (forms are available online in the FORMS link at I must have completed sixteen (16) hours of continuing education in addition to the sixteen (16) continuing education hours required to renew my massage therapy instructor registration as provided in Part 11 of 16.7 NMAC, the Board s rules and regulations. If I do not fulfill all the requirements for registration within one (1) year from the date of receipt of the application by the Board Office, my application will become null and void and any fees paid will be forfeited Print Name: Date: Signature: SchoolBased Instructor Applicant: Return this completed checklist with your application for massage therapy instructor registration. Revised:

8 MASSAGE THERAPY INSTRUCTOR REGISTRATION INDEPENDENT INSTRUCTOR REGISTRATION CHECKLIST Independent Instructor must complete and return this checklist with the application for registration. It is your responsibility to ensure that the requested documentation is provided to the Massage Therapy Board. Failure to complete correctly and/or return this checklist with your application along with the required fee and documentation will cause a delay processing your application. * NA For Office Use Only Date Received ATTACH Complete Application for Massage Therapy Instructor Registration, which is signed before a notary public and includes a 2 x2 photograph of applicant. (Photocopy or scanned photograph is not acceptable.) / / ENCLOSE Application Fee of $50.00, payment made out to: Massage Therapy Board / / ENCLOSE Form A, which outlines the Curriculum and Syllabi / / ENCLOSE Documentation verifying the training received, as outlined in Section E of the application, for the Curriculum and Syllabi outlined in Form A / / *If, date that is will be provided to the Board Office: / / A minimum of three (3) different forms of documentation supporting Massage Therapy experience as outlined in Section D of the application: Income tax forms documenting massage therapy practice Verifiable letters from clients confirming receipt of massage therapy services from the applicant (must include names, addresses, phone numbers, etc.) Yellow pages advertisement(s) that show dates of the ad publication Printed flyers or brochure advertisements with dates Proof of rent or lease of practice location or office space used for massage therapy practice Proof of current professional association membership Proof of current professional insurance Copies of dated receipts for massage therapy practicerelated supplies or furnishings that total a minimum of $500 Verifiable letters from employers (must have names, addresses, phone numbers, etc.) Work log consisting of client s names, addresses, and/or phone numbers, appointment dates, and time periods worked on clients *If NO (not enclosed) please note the date that this documentation will be provided to the Board Office: / / Documentation verifying completion of a minimum of 50 contact hours of instructional experience of professional teaching or workshop instruction. / / / / *If NO (not enclosed) please note the date that this documentation will be provided to the Board Office: / /_ FOR OFFICE USE ONLY Application Deemed Complete Date of Completion / / Copy of Checklist Mailed to Applicant / /, / / / /, / /, / / Board Staff tes: L2000 Database Entry / / LMT LICENSE # STATUS: Date Completed: / / Registration # Issue Date / / Expiration Date: / / Independent Instructor: Return this completed checklist with your application for massage therapy instructor registration Revised:

9 The applicant must complete and submit this section with the checklist and application. All boxes must be checked confirming that you are aware of the following. I understand that the application review process is averaging approximately two (2) to four (4) weeks after receipt by the Board office. It is my responsibility to prove that I meet the minimum requirements for Massage Therapy Instructor Registration The Board cannot waive any of the requirements for registration I must hold a current New Mexico Massage Therapy License I must have a minimum of two (2) years of professional massage therapy experience within the last three (3) years prior to application I must have a completion of a minimum of 50 contact hours of professional teaching/workshop instruction As a Registered Independent Instructor, I can only provide massage therapy instruction within the requirements of the Massage Therapy Practice Act & Rules, and the training shall not include training to students not yet licensed, unless the training is for noncredit All fees paid to the Massage Therapy Board are nonrefundable, even if I withdraw my application for registration I am not to provide massage therapy instruction until I receive a Massage Therapy Instructor Registration issued by the New Mexico Massage Therapy Board Renewal notices are sent out as a courtesy reminder, it is my responsibility to contact the Board and to renew my license if I do not receive a renewal application Failure to renew my license as a Massage Therapist will automatically result in my Massage Therapy Instructor Registration being placed on Inactive Status I must notify the Board Office in writing of any changes (name change, address change, etc.) applicable to my Massage Therapy Instruction Registration I must have completed sixteen (16) Continuing Education hours to include four (4) hours of Ethics in addition to the sixteen (16) Continuing Education hours required to renew my Massage Therapy Instructor Registration If I do not fulfill all the requirements for licensure within one (1) year from the date of receipt of the application by the Board Office, my application will become null and void and any fees paid will be forfeited Print Name: Date: Signature: Independent Instructor: Return this completed checklist with your application for massage therapy instructor registration Revised: