License Application

Applicant Information


First Name:	Middle Initial:	Last Name:	Suffix (Sr., Jr.):


Social Security Number:	Birthdate:	Also Known As:


Are you a U.S. citizen?	Yes	No


Type of Visa:	Visa Number:


Certificate #:	INS #:


Petition #:	Date Issued:	District Court Through Which Issued:



Are you an active member of, or a spouse of, a member of the armed forces of the United States or a reserve component of the armed forces of the United States?	Yes	No

Contact Information

Home Address


Address:
Address Line 2:
City:	State:	Zip Code:
Phone Number:

Contact Email

Contact Email:

Employer Information

Employer Information


Employer List if employed as or will be employed once licensed as Massage Therapist.
Employer Address:		Employer Address Line 2:
Employer City	Employer State	Employer Zip
Employer Phone		Current Employer?