section .0200 - APPLICATION FOR LICENSE

21 NCAC 30 .0201 APPLICATION AND SCOPE

(a) Each applicant for a license as a massage and bodywork therapist shall complete an application. The application shall include the following:

(1) full name (last name, first name, middle name and maiden name, if applicable);

(2) name as the applicant wants it to appear on license (must be part or all of applicant's legal name);

(3) current residence;

(4) mailing address;

(5) city, state, zip code and county;

(6) Social Security Number;

(7) city and state of birth;

(8) date of birth;

(9) telephone number (e.g. home, mobile and business);

(10) email address;

(11) trade name or business name (if applicable);

(12) business address;

(13) type of license applying for (Regular, License by Endorsement A or License by Endorsement B);

(14) examination agency (FSMTB, NCCAOM or NCBTMB, if applicable);

(15) exam taken (MBLEx, NCETMB, NCETM or ABTE, if applicable);

(16) whether or not a U.S. citizen;

(17) physical description (gender, height, eye color, race, weight and hair color);

(18) place of residence for the previous 10 years including date, street address, city, state, zip code and county;

(19) professional experience for the previous 10 years including date, job title, type of business, hours worked per week, employer's name, address, state, zip code, area code and phone number and reason for leaving, if applicable;

(20) education (high school, college/university, graduate or professional) including name of educational institution, city, state, zip code, whether or not you were issued a certificate, diploma or degree and month and year of graduation;

(21) previous or current licensure, registration or certification in another state or territory, including state, license, registration or certification type, license or credential number, date issued and date of expiration;

(22) professional affiliations and achievements;

(23) whether the applicant has had any of the following situations and explain such instances:

(A) charged with, arrested for, convicted of, or plead guilty or no contest to a violation of any law;

(B) had a driver's license canceled, suspended or revoked;

(D) violated any federal or state statue or rule which relates to massage and bodywork therapy or any other healthcare profession;

(E) obtained or attempted to obtain compensation by fraud or deceit;

(F) involved in a civil suit related to your practice of massage and bodywork therapy or other healthcare profession;

(G) had any judgments entered against you;

(H) expelled, fired, asked to resign or otherwise suspended from any educational institution;

(I) fired, asked to resign or otherwise suspended from employment;

(J) denied a massage therapy license or a license for any other healthcare profession;

(K) had a license revoked or suspended;

(L) have any formal disciplinary charges pending or action taken by any massage or bodywork therapy licensing board or medical board;

(M) been diagnosed with a mental illness;

(N) been diagnosed as being dependent on alcohol or drugs;

(O) abused alcohol or drugs;

(P) been evaluated or treated for mental health or substance abuse issues;

(Q) used any drug or alcohol to the extent it adversely affected your professional competence or employment;

(24) an attestation under oath before a notary that the information on the application is true and also complete an affidavit of applicant to the Board of all information pertaining to the application.

(b) This application shall be submitted to the Board and shall be accompanied by:

(1) One original color photograph of the applicant taken within six months preceding the date of the application of sufficient quality for identification. The photograph shall be of the head and shoulders, passport type, two inches by two inches in size;

(2) The proper fees, as required by Rule .0204 of this Section and G.S. 90-629.1(b);

(3) Documentation that the applicant has earned a high school diploma or equivalent;

(4) Documentation that the applicant is 18 years of age or older;

(5) Documentation that the applicant has completed a course of study at a school approved by the Board according to these rules and consisting of a minimum of 500 classroom hours of supervised instruction. If the applicant attended a school that is not approved by the Board, the Board may elect to review that applicant's curriculum on a case-by-case basis. The documentation of such training shall come from a school that is licensed by the educational licensing authority in the state, territory or country in which it operates. In North Carolina the documentation shall come from a proprietary school approved by the Board or a college-based massage program that is exempt from Board approval. The curriculum shall meet or be substantially equivalent to the standards set forth in Rule .0620(2) of this Chapter;

(6) Documentation that the applicant has achieved a passing score on a competency assessment examination administered by the Board or approved by the Board that meets generally accepted psychometric principles and standards;

(7) Signed statements from four persons attesting to the applicant's good moral character;

(8) Fingerprint card executed by a fingerprinting agency, and

(9) Consent to a criminal history record check by the North Carolina Department of Justice.

History Note: Authority G.S. 90-626(2); 90-629;

Temporary Adoption Eff February 15, 2000;

Eff. April 1, 2001;

Amended Eff. October 1, 2008;

Readopted Eff. October 1, 2015.