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Get TX DSHS Publication F64-10701 2009-2021

MASSAGE THERAPY LICENSING PROGRAM TEXAS DEPARTMENT OF STATE HEALTH SERVICES P. O. Box 149347 Mail Code 1982 Austin Texas 78714-9347 OUT OF STATE LICENSE VERIFICATION The application for licensure as a Massage Therapist in the State of Texas requires this form to be completed by all State Boards where I hold or have ever held a license. My signature below is your authorization to release all information in your files favorable or otherwise regarding myself* Section I to be completed by applicant. Please type or print clearly. Applicant Name License Number Applicant s Signature Date Address P O Box or Street No* City State Zip Telephone Number include area code Date of Birth Section II. Completed by out-of-state licensing authority State of. This certifies that is Registered Certified Licensed as a Current status of this license/license/certification is Active Lapsed Inactive Denied Suspended Revoked Effective date of License/Registration/Certification Please attach a copy of the Findings of Fact and Decision and Order. License/Registration/Certification issued based on Education Requirements Endorsement/Reciprocity State Examination Grandfather Requirements National Examination Qualifications for licensure in this state are a* Total hours of education b. Number of hours required in Swedish Massage d. Written examination required Yes No e. Practical examination required Yes been sent to this office within the last 12 months please disregard this request. I certify that the above information is correct and true. I have enclosed a copy of the requirements for this state. Name of Agency Address Signature Typed Name Title Date STATE SEAL DSHS Publication F64-10701 Massage Therapy Application Revised 5/09. My signature below is your authorization to release all information in your files favorable or otherwise regarding myself* Section I to be completed by applicant. Please type or print clearly. Applicant Name License Number Applicant s Signature Date Address P O Box or Street No* City State Zip Telephone Number include area code Date of Birth Section II. Please type or print clearly. Applicant Name License Number Applicant s Signature Date Address P O Box or Street No* City State Zip Telephone Number include area code Date of Birth Section II. Completed by out-of-state licensing authority State of. This certifies that is Registered Certified Licensed as a Current status of this license/license/certification is Active Lapsed Inactive Denied Suspended Revoked Effective date of License/Registration/Certification Please attach a copy of the Findings of Fact and Decision and Order. Completed by out-of-state licensing authority State of. This certifies that is Registered Certified Licensed as a Current status of this license/license/certification is Active Lapsed Inactive Denied Suspended Revoked Effective date of License/Registration/Certification Please attach a copy of the Findings of Fact and Decision and Order. License/Registration/Certification issued based on Education Requirements Endorsement/Reciprocity State Examination Grandfather Requirements National Examination Qualifications for licensure in this state are a* Total hours of education b. .

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