application for licensure or registration in massage therapy - dhmh

COPY OF NON EXPIRED DRIVER’S LICENSE OR STATE ID CARD. New Residents to MD provide copy of MD D.L/ID □ DISCIPLINARY PAGE COMPLETED AND A COPY OF CRIMINAL HISTORY RECORDS FINGERPRINT RECEIPT

MD STATE BOARD OF MASSAGE THERAPY EXAMINERS – 4201 PATTERSON AVE., SUITE 301, BALTO., MD 21215 MAIN OFFICE ► 410-764-4738 ◊ LICENSING COORDINATOR ►410-764-4665

AP PLI C ATI ON FOR LI CENSE OR REGI STR AT I ON

I N M ASS AGE T HER APY (PAGE 1 OF 10)

I M P O R T A N T I N F O R M A T I O N – R E A D A L L I N F O R M A T I O N *APPLICATION – DATE MAILED:

*PRIOR LICENSE OR REGISTRATION HELD WITH

THIS BOARD DATE: NO:

Fillable PDF to print out - I herewith enclose this completed typed application with the following requirements: HAVE GRADUATED FROM AN ACCREDITED MASSAGE PROGRAM WITH A MINIMUM OF 600 HOURS (Any questions please contact this Board’s Administrator).

*Before Completing this Application READ The MD State Board of Massage Therapy Examiners Lawsand Regulations. The Laws & Regulations can be located at: health.maryland.gov/massage

(YOU MUST CHECK OFF ALL REQUIREMENTS IN BELOW LIST CONFIRMING SUBMISSIONS W/ APPLICATION). TOTAL FEES DUE WITH THIS APPLICATION: $300.00 (Application Fee $150 + JP Exam Fee $150) One Money Order or Bank Cashier’s Check FOR EACH APPLICANT made payable to: “MD State Board of Massage Therapy Examiners”)

ATTACHED [see page(s) 9-11] FOR IN STATE. FOR OUT OF STATE APPLICANTS; CONTACT THE BOARD TO REQUEST THE FINGERPRINT CARD [see page(s) 9-10] [Effective Jan. 1, 2015] PRINTS MUST NOT BE MORE THAN 30 DAYS OLD.

□ (2) 2 X 2 PASSPORT TYPE PHOTOGRAPHS ON WHITE BACKGROUND (ON PHOTO PAPER)

□ NOTARY PAGE IS COMPLETED BY APPLICANT IN THE PRESENCE OF NOTARY AND CONTAINS NOTARY SEAL

□ UNOFFICIAL COPY OF MASSAGE TRAINING TRANSCRIPT(S) SHOWING COMPLETION / GRADUATION FROM THE MASSAGE PROGRAM WITH A MINIMUM OF 600 HOURS AND IN INTERIM– Request Official be Sent to Board

□ UNOFFICIAL COPY OF ALL COLLEGE TRANSCRIPTS OF 60 CREDITS OR MORE REGARDLESS OF AREA OF STUDY

□ COPY OF SCORE REPORT (MBLEX OR NCBTMB EXAM(S) REPORT FOR APPLIC. Request Official be sent to Board

□ COPY OF YOUR VALID CPR CERTIFICATION> LMT=Healthcare Provider Level OR RMP = BASIC CPR

□ REQUESTED ALL OFFICIAL EDUCATION TRANSCRIPTS & OFFICIAL SCORE REPORT BE SENT BY ISSUER TO BOARD. □ ALL REQUIRED INFORMATION COMPLETED WITH NO BLANKS – This is a Fillable Form.

IMPORTANT: All of the above must be received by the Board BY THE POSTMARK DEADLINE DATE. No exceptions. Examination Dates and Exam Study Guide which is the MD State Laws & Regulations are posted on the website: health.maryland.gov/massage

APPLICANT’S INFORMATION

Legal Last Name First Name Middle Initial

Full Maiden Name / Transcript Name / Other Name if different from above (if applicable provide supporting documents – court order, marriage cert.,etc.)

THE MAILING ADDRESS PROVIDED BELOW IS MY: □ Residence □ Business Address (complete top - pg.2) □ Both

Residence/Mailing Address City State Zip Code

Telephone Number: Cell Number: Email:

Soc. Security Number: DOB-Month: Day: Four Digit Year: Age:

Must Complete PRIOR MAILING ADDRESS (Applicants New to the State of MD [less than 1 year] or Out of State Applicants)

Residence/Mailing Address City State Zip Code

Current Work/Employment Address

Business Name: Address: City State Zip Code

(Note): Your address will be the official mailing address maintained in your file and should be the legal address to which you receive all mail. All official Board mail during the application process will be sent to you at that address. If the mailing address changes at any time it is your responsibility to inform the Board IN WRITING. Once licensed or registered by the Board; by law, YOU MUST PROVIDE ANY CHANGES TO YOUR BOARD MAILING ADDRESS IN WRITING DIRECTLY TO THE BOARD WITHIN 60 DAYS OF THE CHANGE OR MOVE REGARDLESS IF TEMPORARY. FAILURE TO COMPLY MAY RESULT IN AN ADMINISTRATIVE FINE OF $100 PER REGULATIONS.

http://www.dhmh.maryland.gov/massage


AP P L I C AT I O N F O R L I C E N S E OR RE G I S T R AT I O N I N M AS S AG E T H E R AP Y (PAGE 2 OF 10)

APPLICANT’S LAST NAME: SOCIAL SECURITY NUMBER: XXX-XX-

(There is no authority to require your disclosure of birth date or Social Security Number. 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 assess your identity, background, and qualifications).

To further its commitment to equal opportunity, the State Board of Massage Therapy Examiners request applicants to provide VOLUNTARILY, the following information. This information will be used for statistical purposes only by authorized personnel. Race/ethnic identification – please check all that apply:

1. Hispanic or Latino origin (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race).2. American Indian or Alaska Native (a person having origins in any of the original peoples of North or South America, including Central America, and who

maintains affiliations or community attachment). 3. Asian (a person having origin in any of the original peoples of the Far East, Southeast Asia or the Indian subcontinent including, for ex. Cambodia, China,

India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam). 4. Black or African American (a person having origins in any of the black racial groups of Africa).5. Native Hawaiian or other Pacific Islander (a person having origins in the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands).6. White (a person having origins in any of the original peoples of Europe, the Middle East or North Africa).7. Other.8. Are you a Veteran or Spouse of a Veteran of the U.S. Armed Services? If “Yes”, please state the date of Discharge/Active Duty /__/ . (Copy of

military ID w/ application – for expedited processing – Spouse of Veteran need to provide both individuals ID’s and Copy of Marriage Certificate). Proof of Military Status Documents and Proof of Military Spouse – Currently with the aforementioned evidence: No Application Fee and JP Exam fee is required.

9. Prefer Not to AnswerRequired

10. Gender □ Male □ Female

APPLICANT’S OUT OF STATE OR IN STATE LICENSES, CERTIFICATES AND REGISTRATIONS EVER HELD READ [ALL HEALTHCARE RELATED LICENSURE, CERTIFICATES, REGISTRATION OUTSIDE OF THIS BOARD MUST HAVE AN OFFICIAL VERIFICATION OF

GOOD STANDING SENT DIRECTLY TO THIS BOARD BY THE ISSUING STATE – No Exceptions]

LICENSE/REGISTRATION/CERTIFICATE NUMBER: ISSUING AGENCY/DEPT: ORIGINAL DATE / EXPIRATION DATE:



CRIMINAL HISTORY RECORDS CHECK INFORMATION & BACKGROUND CHECK INFORMATION

ALL APPLICANTS MUST HAVE AN OFFICIAL CRIMINAL HISTORY RECORDS CHECK (CHRC) – BY FINGERPRINTING (EFFECTIVE JANUARY 1, 2015). [THE GUIDELINES / FORM FOR CHRC IS ATTACHED TO THIS APPLICATION PACKET]. NOTE: OUT OF STATE

APPLICANTS MUSTCONTACT THE BOARD AT [410-764-4738] TO REQUEST THIS BOARD’S OFFICIAL ‘OUT OF STATE

FINGERPRINT CARD’ TO BE MAILED DIRECTLY TO THE APPLICANT BEFORE THE REMITTANCE OF THE MASSAGE THERAPY APPLICATION TO THIS BOARD. THE FINGERPRINTING RECEIPT MUST BE INCLUDED WITH THE APPLICATION BEING SUBMITTED BY THE APPLICATION DEADLINE DATE. THE AFOREMENTIONED REQUIREMENT IS IN ADDITION TO ANSWERING THE FOLLOWING DISCIPLINARY QUESTIONS.

DISCIPLINARY / BACKGROUND INFORMATION: Answer ALL questions and provide complete accurate answers to avoid

delays AND / OR a possible denial in the processing of your application. Any “Yes” response(s) require a detailed explanation.

1. Have you ever been denied a license, certificate, or registration? YES NO If “Yes” explain all reasons in detail:

Please use additional paper as needed for the detailed explanation and attach to this page 2.

2. Have you ever had a license, certificate or registration revoked, suspended, canceled, or investigated?YES NO

If “Yes” explain all reasons in detail on the in this block and the following page 3:


AP P L I C AT I O N F O R L I C E N S E O R RE G I S T R AT I O N I N M AS S AG E T H E R AP Y (PAGE 3 OF 10)



3. Have you ever appeared in court, been arrested, or entered a plea or any kind inclusive of guilty, no contest, nolocontendere or been convicted of a crime or received probation before judgement in any jurisdiction for a crimeother than a minor traffic violation? YES NO

If “Yes” provide the following information first: Charge(s) for which you appeared in court(s): Court Name and Full Address to which you appeared: Date(s) involved for all court appearances:

If “Yes” secondly provide all details in an explanation to the Board.


Note: Any Court Case(s) to which you were involved; you MUST also attach documentation and information as

follows:

*All documents pertaining to arrest, conviction, probation, parole or disposition of the case(s).*Detailed statement of your education, social and rehabilitative activities or any supervision since

conviction.

[STOP AND TAKE NOTICE] [ATTACH A COPY OF THE RECEIPT FROM HAVING YOUR CRIMINAL HISTORY RECORDS CHECK (FINGERPRINTING) DONE TO THIS PAGE.]

HOW TO OBTAIN - PER INSTRUCTIONS ON PAGE(S) 8 – 10 FOR MARYLAND RESIDENTS AND PAGE(S) 9-10 FOR OUT OF STATE APPLICANTS]




PROFESSIONAL TRAINING – EDUCATIONAL CREDENTIALS

LIST ALL Educational Credentials starting with the massage therapy training programs completed from proprietary, trade schools and/or college programs attended to satisfy the academic requirements for a license or registration in massage therapy.

Then LIST ALL subsequent educational credentials outside of the massage therapy programs. LIST ANY HIGHER EDUCATION COMPLETION OF 60 OR MORE CREDITS TO BE EVALUATED FOR THE LMT STATUS AND PROVIDE COPIES OF ALL UNOFFICIAL TRANSCRIPT(S) WITH THIS APPLICATION. IF APPROVED – OFFICIAL TRANSCRIPT(S) MUST BE REQUESTED BY THE APPLICANT AND SENT DIRECTLY TO THIS BOARD FROM THE ISSUING COLLEGE/INSTITUTION. COMPLETE ALL FIELDS/BLANKS WITH ACCURATE INFORMATION – INCOMPLETE INFORMATION MAY CAUSE DELAY

NAME OF INSTITUTION: GRADUATION/COMPLETION DATE:

COMPLETE BUSINESS ADDRESS:

BUSINESS PHONE: EMAIL: WEBSITE:

PROGRAM HOURS / CREDITS TOTAL: ACCREDITED BY OR APPROVED TO OPERATE BY:

NAME OF INSTITUTION: GRADUATION /COMPLETION DATE:



PROGRAM HOURS/CREDITS TOTAL: ACCREDITED BY OR APPROVED TO OPERATE BY:

NAME OF INSTITUTION: GRADUATION/COMPLETION DATE:



PROGRAM HOURS/CREDITS: ACCREDTIED BY OR APPROVED TO OPERATE BY:

ALTHOUGH PHOTOCOPIES OF TRANSCRIPTS AND SCORE REPORTS MUST ACCOMPANY THE INITIAL APPLICATION IN ORDER TO SIT FOR THE JURISPRUDENCE EXAMINATION; ENSURE THAT YOU HAVE CONTACTED ALL SCHOOLS, COLLEGES, AND INSTITUTIONS IN THE INTERIM TO REQUEST THAT THE OFFICIAL TRANSCRIPT(S) AND SCORE REPORT(S) BE SENT DIRECTLY TO THIS BOARD BY THE ISSUING SCHOOL, COLLEGE, INSTITUTION AND NATIONAL ORGANIZATION(S).

NOTE: FAILURE TO SUBMIT A COMPLETED APPLICATION WITH REQUIRED DOCUMENTATION WILL DELAY YOUR PROCESSING AND ABILITY TO SIT FOR THE EXAM TO WHICH YOU MET THE DEADLINE REQUIREMENT.

*OFFICIAL TRANSCRIPT(S) AND SCORE REPORTS MUST BE MAILED DIRECTLY TO THIS BOARD BY THE ISSUING EDUCATIONAL INSTITUTION, MASSAGE PROGRAM; COLLEGE; UNIVERSITY, OR TRADE SCHOOL.

IT IS THE APPLICANT’S RESPONSIBILITY TO REQUEST AT THE TIME OF COMPLETING THIS APPLICATION BEFORE REMITTING IT TO THIS BOARD; THAT THE OFFICIAL TRANSCRIPT(S) AND SCORE REPORT BE SENT DIRECTLY TO THIS BOARD BY THE ISSUING

ENTITY/AGENCY SUBMISSIONS FROM THE VARIOUS ENTITIES CAN BE MAILED TO:

MD STATE BOARD OF MASSAGE THERAPY EXAMINERS 4201 Patterson Ave., Suite 301

Baltimore, MD 21215 Attn: Emily Jones, Licensing Coordinator




PROFESSIONAL REFERERENCES (Not Friends, Relative, Individuals who do not know you OR Individuals who are illegally practicing in this state)

Provide a minimum of three (3) Professional References that can attest to your massage therapy skills, professional standards of practice, clinical work and moral character. These persons should work in the massage therapy field such as instructors, professors, independent practitioners or individuals in related professions such as chiropractic, physical therapy, or medicine. The individual(s) you choose to disclose MUST know that you are listing them as a professional reference.

COMPLETE THIS SECTION WITH ACCURATE INFORMATION AND COMPLETE INFORMATION TO AVOID DELAYS. FALSE INFORMATION WILL DELAY PROCESSING AND/OR MAY POSSIBLY BE CAUSE FOR

DISCIPLINARY ACTION.

NAME OF REFERENCE:

BUSINESS NAME & ADDRESS:

BUSINESS PHONE/CELL: EMAIL:

PROFESSIONAL OCCUPATION: LICENSE NO.: REFERENCE HAS KNOWN YOU HOW LONG?

Will this reference be verifying all or some of your clinical exp.? YES NO

NAME OF REFERENCE:





NAME OF REFERENCE:





NOTE:

DID YOU COMPLETE ALL BLANKS WITH ACCURATE VERIFIABLE INFORMATION TO AVOID DELAYS IN PROCESSING?

AS INDICATED PRIOR, THE REFERENCE INDIVIDUALS SHOULD KNOW THAT YOU ARE USING THEM AS A REFERENCE

AND YOU SHOULD HAVE OBTAINED ALL CURRENT INFORMATION INCLUSIVE OF ADDRESSES AND TELEPHONE NUMBERS. FAILURE TO COMPLETE THIS SECTION COMPLETELY AND ACCURATELY MAY BE CAUSE TO SEND YOUR APPLICATION BACK AS AN INCOMPLETE APPLICATION AND MAY DELAY YOUR APPLICATION PROCESS; IF THE BOARD CANNOT CONFIRM THE AFOREMENTIONED INFORMATION.


AP P L I C AT I O N F O R L I C E N S E O R RE G I S T R AT I O N I N M AS S AG E T H E R AP Y

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ATTESTATION READ CAREFULLY, PRESENT IDENTIFICATION AND SIGN IN PRESENCE OF NOTARY

LEGAL FIRST NAME: Middle Initial: LAST NAME:

I have read the all the important notices, notes throughout the application. I understand their content (Initials)

In making this application to the Maryland State Board of Massage Therapy Examiners, I agree to abide by all laws, rules and regulations of the Board governing massage therapy found in Maryland Code Annotated, Health Occupations Article § 3-5A-01 et seq. and in the Code of Maryland Regulations 10.65.01 et seq. and to take all examinations necessary for the processing of my application. Upon issuance of a license 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 licensure or registration.

I agree to hold the Maryland State Board of Massage Therapy Examiners, 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 license 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 license or registration to practice massage therapy, upon suspension, revocation, or cancellation of such license or registration; I shall return the official license or registration back 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.

P r i n t F u l l L e g a l N a m e S i g n a t u r e o f F u l l L e g a l N a m e D a t e

N O T A R Y A T T E S T A T I O N

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,

Signature of Notary

Printed or Typed Name of Notary (SEAL) (SEAL)

(APPLICANT’S RECENT PASSPORTY TYPE PHOTO)

2” x 2” PHOTO HERE

WHITE BACKGROUND (PHOTO IN THIS AREA)


APPLICATION FOR LICENSE OR RE GISTRATION IN MASSAGE THERAPY

(PAGE 7 OF 10)

APPLICANT’S LAST NAME: SOCIAL SECURITY NUMBER: XXX‐XX‐

MARYLAND STATE BOARD OF MASSAGE THERAPY EXAMINERS – JURISPRUDENCE EXAMINATION INFORMATION

Please Note: NO ELECTRONIC DEVICES AT ALL ARE ALLOWED AT THE EXAM SITE (This includes all smart

technology devices developed after year 2000 to present and devices pending patents from the years 2000 to

present). Leave any aforementioned electronic device in your vehicle.

2018 Examination Dates and Application Deadlines

Exam Date Application Postmark Deadline

Monday, December 18, 2017 December 1, 2017 * (see red notations below)

Monday, January 29, 2018 January 2, 2018 * (see red notations below)

Monday, February 26, 2018 February 1, 2018 * (see red notations below)

Monday, March 26, 2018 March 1, 2018 * (see red notations below)

Monday, April 23, 2018 April 2, 2018 * (see red notations below)

Monday, May 21, 2018 May 1, 2018 * (see red notations below)

Monday, June 25, 2018 June 1, 2018 * (see red notations below)

Monday, July 30, 2018 July 3, 2018 * (see red notations below)

Monday, August 27, 2018 August 1, 2018 * (see red notations below)

Monday, September 24, 2018 September 4, 2018 * (see red notations below)

NO EXAMINATION – RENEWALS License / Registration Printing for Renewal

Monday, November 19, 2018 November 1, 2018 * (see red notations below)

Monday, December 17, 2018 December 3, 2018 * (see red notations below)

*2018 Renewal Year - New licensees/registrants will have to renew their license/registration regardless of the date of initial license

or registration. However any licenses/registrations issued on or after October 31, 2017 will be exempt from continuing education

requirement. Candidates taking the JP Exam in the Summer of 2018 can elect not to submit the Data Sheet for license or

registration printing until Aug. 10th to avoid the 2018 Renewal of that license/registration. However Note: Those who elect to

wait CANNOT PRACTICE MASSAGE THERAPY UNTIL A VALID LICENSE/REGISTRATION HAS BEEN ISSUED TO DISPLAY.

Scheduling of a specific exam date AND receipt of an “Admittance Letter” after review is predicated on a completed application

containing the required documentation as stipulated on the “check‐off” list of the first page of this application AND the

application remitted to this Board postmarked by the deadline date. Again, in order to be able to sit for the Jurisprudence Exam;

ALL applications must include the following photocopies: unofficial transcripts [massage training program completion,

college transcripts (if applicable), unofficial score report [either FSTMB – MBLEx, NCBTMB, or NCCAOM], CPR certification

[for status as RMP– Basic CPR or for status as LMT – Provider Level CPR], and copy of Criminal History Records Check (CHRC)

fingerprinting payment receipt.

Total Fees Due must be paid by Money Order, Bank Certified Check, School/Institution Business Check or State Agency

Business Check and can be one check with for Application Fee and Jurisprudence Exam Fees only. Actual Payment for the

physical License or Registration can only be remitted once an applicant receives a passing examination letter accompanied by an

official Board Datasheet which is remitted back with the fee for the actual printing of the license or registration. All fees must

be payable to the Maryland State Board of Massage Therapy Examiners.

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AP P L I C AT I O N F O R L I C E N S E O R RE G I S T R AT I O N I N M AS S AG E T H E R AP Y

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WHAT HAPPENS AFTER THE JURISPRUDENCE EXAMINATION?

MASSAGE THERAPY – POST EXAM PROCEDURES

Please adhere to the following:

DO NOT call the Board for your MD JP Exam Scores. The exams are scored as quickly as possible within 5 – 7 days depending on the number of candidates seated for the exam. Candidates are notified within 10 – 15 days or earlier in writing by chronological order of the date by which the Board received the completed application (note below). If you have not received written notification via email (if you provided an email on your application or exam disclosure forms) or by USPS mail (if you do not have an email); then the conclusion that can be drawn is that you may still have an incomplete application because either:

You did not request the Official Documents be sent directly to this Board or your Official Documents have not

been received by the Board as yet. Such Official documents are: the (Massage Therapy Transcript, FSMTB Score

Report, NCBTMB Score Report or College Transcript(s) if you qualify for LMT status OR your Criminal History

Records Check (CHRC) result has not been received). For CHRC please contact CJIS then the Board’s Investigator.

STEPS TO MOVE THE PROCESS FORWARD:

First: Contact your massage training school to ensure that your Official Transcript showing that

you have COMPLETED AND GRADUATED FROM THE MASSAGE THERAPY PROGRAM has be sent

directly to the Board as outlined in the Application AND inquire as to when the school sent it out.

Second: Contact your Testing Agency to ensure that your Official Score Report has been sent directly

to this Board AND inquire when the agency sent it out.

Note: You may contact the Board after 5 business days if you have new or updated information regarding the status of your Official Documents or changes in address or email address.

Third: Be on the lookout for an email with an attachment or USPS mail for the Exam Pass/Fail letter along with the Board Data Sheet which will be enclosed for you to complete with your legal name and information and remit back with the $200 license or registration fee for the actual printing of your license or registration. It will need to be remitted back to this Board by MAIL.

Generally the entire process after exam passing notification takes less than 14 business days; predicated

on when the applicants submits back the complete datasheet with the license/registration fee.

Please be advised; if you choose to get your license or registration now without the benefit of full 2 years; there is no proration of fees, refunds, or waivers. The expiration date on the license or registration is the expiration of that document and if your original license or registration date falls close to a biennial renewal; then you are responsible to renew.

Note: Your contact after you have ensured that you have complied with all of the above requirements is Ms. Emily Jones, License Coordinator at [email protected] or (410) 764-4665. Status change from RMP to LMT, concerns or complaints is to be sent to Adrienne Congo, Deputy Director & Massage Therapy Program Manager at [email protected] .

mailto:[email protected]%20or%20(410)%20764-4665.

mailto:[email protected]


BOARD POLICY REGARDING APPLICANT’S FAILURE OF THE JURISPRUDENCE EXAMINATION

1ST

RETEST FEE $200. If an applicant fails for the 3rd

time; he/she must wait 30 days before retaking the exam. 4th

failure must appear before the Board. Individuals with a completed application and fails to take the JP Exam within 12 months of the initial

submission to the Board will forfeit original application and exam fee and must resubmit all required fees.

The following policy pertains to applicants for massage licensure or massage registration. There are no waivers or exceptions to the following:

All applicants shall successfully take and pass the Board Jurisprudence Examination to qualify

for licensure or registration.

All applicants must appear for the examination at the time/date specified. Applicants who fail to appear without prior notification must wait at least thirty (30) days from the date of the unexcused absence to retest AND must pay a retest fee of $200. There are no refunds for unexcused absences. (One reschedule will be accepted with at least 24 Hour prior notification via fax, email or confirmed phone notification for extenuating circumstances).

If an applicant passes the examination the applicant’s file will be submitted for further processing.

An applicant failing the examination the first time may retest at the next available examination

date.

An applicant failing the examination a second time may retest again only after waiting at least (60) days from the date of the second failure.

An applicant failing the examination a third time may retest only after waiting at least ninety

(90) days from the date of the third failure, meeting with the Board at its request, and recommended approval of the Board. Final approval regarding retesting availability will be made by the Board upon written request of the applicant.

An applicant’s file shall be closed/terminated one (1) year from the original application date

regardless of the status of the applicant in the exam process. At such occurrence, the applicant may reapply for qualification and submit all required fees, documentation, and form as a new applicant. Any/all previous failures will be applied to the new application. For example, an applicant failing the exam three (3) times under the first application and then reapplying after lapse of one year, will still have three (3) failures credited to the application and would have to obtain approval of the Board to retest.

Acknowledgement

I, have read and fully understand all of the provisions of the foregoing policy.

Signature Date

STATE OF MARYLAND

DHMH Maryland Department of Health and Mental Hygiene

Maryland State Board of Massage Therapy Examiners Larry Hogan, Governor – Boyd Rutherford, Lt. Governor – Dennis R. Schrader, Secretary

Criminal History Records Check

A full Criminal History Records Check (CHRC) is a requirement for a license or registration from the Maryland Board of Massage Therapy Examiners. A full background check includes both State and FBI checks. The Department of Public Safety and Correctional Services, Criminal Justice Information System (CJIS) oversees Criminal History Record Checks. History record checks are conducted by being fingerprinted.

CJIS AUTHORIZATION #: 1600004151

FBI ORI #: MD 920519Z

REASON FINGERPRINTED: Massage Therapy License or Registration

TYPE OF CHECK: Governmental Licensing/Certification

The cost is $50.00 ($30.00 background check and $20.00 fingerprinting service). However, the cost of fingerprinting services from private providers can vary. The fee must be paid directly to the provider. CASH IS NOT ACCEPTED. For additional information contact CJIS at 410-764-4501 or visit www.dpscs.maryland.gov/publicservs/fmgerprint.shtml.

All applicants for licensure or registration in Maryland will be required to submit fingerprints. This can be accomplished in two ways depending on if you are a Maryland resident or not. In order to comply with the regulations and not delay the issuance of a license or registration, follow the following directions on the following page(s).

http://www.dpscs.maryland.gov/publicservs/fmgerprint.shtml

FOR Maryland Residents 1. Fill out and print a copy of the attached “Livescan Pre-Registration Application” form.

Go to www.dpscs.maryland.gov/publicservs/fingerprint.shtml for a list of commercial fingerprint providers near you. Take the “Livescan Pre-Registration Application” form to the commercial fingerprint provider with you when you are scheduled to be fingerprinted.

2. When you have your fingerprints taken you will be given a receipt for payment. Include

a copy of the receipt when filing your initial application. 3. Once the results of the background check are received the application process will

be completed in accordance to Board regulations and policies. For additional information contact CJIS at 410 764-4501 or visit www.dpscs.maryland.gov/publicservs/fingerprint.shtml

FOR Out of State Residents NOTE: If you live or work close to Maryland; you have the option of using a Maryland location

for your fingerprinting. If you use a Maryland location, you can fill out and print a copy of the attached “Livescan Pre-Registration Application” form. Go to www.dpscs.maryland.gov/publicservs/fingerprint.shtml for a list of commercial fingerprint providers near you. Take the “Livescan Pre-Registration Application” form to

the commercial fingerprint provider with you when you are fingerprinted. If not,

1. Before submitting a completed application, contact the Board (410) 764-4738 to request an “Application For Criminal History Records Check” stock card to be mailed directly to you (as the receipt of fingerprinting must be enclosed within your application).

2. Have your fingerprints taken at a law enforcement agency near you.

3. Once you have your prints taken, you MUST mail the fingerprint cards to the below address with a check for $30.00 made out to the "CJIS Central Repository". No cash or money orders.

Mail To: CJIS Central Repository P.O. Box 32708 Pikesville, Maryland 21282-2708

4. Enclose with your Application a copy of the receipt for the fingerprinting to:

Maryland Board of Massage Examiners, 4201 Patterson Avenue, Baltimore, MD 21215; Attn: Emily Jones, Licensing Coordinator

5. Once the results of the background check are received, which can take up to

four weeks (it will not preclude you from taking the exam). However, only when your application is complete with all documents and review sign-offs will the process for the physical license or registration continue to which the application process will be completed in accordance to Board regulations and policies.

http://www.dpscs.maryland.gov/publicservs/fingerprint.shtml

