Section Plc 902.06 - Initial Massage Therapist License Application(a) Any person who wishes to engage in the practice of massage therapy shall first complete and submit a "Massage Therapist Licensure Application" form for a massage therapist license.(b) Each applicant for licensure as a massage therapist shall complete and submit a "Massage Therapist Licensure Application" form for licensure which contains the following: (1) The applicant's legal name;(2) The applicant's home and mailing address;(3) The applicant's email address;(4) The applicant's home telephone and cell phone number;(5) A recent 2" x 2" photograph of the applicant's face;(6) The applicant's date or birth;(7) The applicant's social security number as required by RSA 161-B:11, VI-a;(8) The name and address of the massage therapy schools attended, enrollment date, and graduation date;(9) An official copy of the diploma or certificate received from the massage therapy school;(10) Verification that the applicant has completed the educational requirements of Plc 902.02, as follows: a. The applicant shall submit his or her official school transcripts from the massage therapy school that the applicant attended; andb. If any part of the applicant's massage therapy education was through distance learning, those courses shall meet the requirements for distance learning in accordance with Plc 902.02(c);(11) Documentation of passage of a written exam in accordance with Plc 902.05;(12) The name of each state where the applicant holds or has held a license or certificate to practice massage therapy and the number of years the applicant has practiced in each state;(13) A copy of the applicant's current first aid certification;(14) A copy of the applicant's current adult CPR certification;(15) A statement verifying that the applicant is in good mental and physical health in accordance with RSA 328-B:6, I(d) and, if not, an explanation of such circumstances;(16) A statement that the applicant has not been convicted of any crime involving violence inflicted on a person or threatened against a person, or any sexually-related crime, in New Hampshire or any other state in accordance with RSA 328-B:6, I(c) and, if yes, an explanation of such circumstances; and(17) The applicant's dated signature below the following pre-printed attestation: "By my signature I attest full compliance with RSA 328-B and all corresponding New Hampshire regulations and that the information and documentation provided are accurate to the best of my knowledge. I understand that knowingly providing false information may be grounds for denial, suspension, and/or revocation of a license."
(c) The completed application shall be submitted to the executive director and accompanied by the fee set forth in Plc 908.N.H. Admin. Code § Plc 902.06
(See Revision Note #1 at chapter heading for Plc 900) #12621, eff 9/21/2018; (formerly Plc 302.06) (see Revision Note #2 at chapter heading for Plc 900).