North Carolina Administrative Code › Title 21 - OCCUPATIONAL LICENSING BOARDS AND COMMISSIONS › Chapter 30 - MASSAGE AND BODYWORK THERAPY › Section .0200 - APPLICATION FOR LICENSE › Section 30 .0201 - APPLICATION AND SCOPE

Current through Register Vol. 39, No. 2, July 15, 2024
(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;
(C) pending
				charges in any state or jurisdiction;
(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.