License Application

Applicant Information

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:


Drop file(s) here or Maximum files: 1. Uploaded File(s) Click here for recommendations on uploading files.
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

Contact Information


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