:: Initial Applications ::

Instructions Step 1 / 14

Fee Schedule

Application Fee: $100

Each Establishment with a Separate Address regardless of owner is required to pay a license fee for each establishment

***YOU MUST ATTACH A COPY OF YOUR CURRENT BUSINESS LIABILITY INSURANCE POLICY; OTHERWISE, YOUR APPLICATION WILL NOT BE REVIEWED BY THE BOARD.***

Screen Guide Step 2 / 14

Screen Layout

Reviewing Completed Application

Printing Application

Establishment Information Step 3 / 14

Name of Establishment

Physical Address of Establishment

Zip

City

State

Contact Name

Mailing Address Information

Address 1

Address 2

Zip Code

City

State

Phone Number

Fax Number

Owner Information Step 4 / 14

Enter one or more Owner or Legal Agent

Establishment first date of operation

Licensure Status Step 5 / 14

Has the owner(s) of the proposed establishment ever held a license for a massage establishment or been a massage therapist in the State of Alabama that has been revoked, suspended, placed on probation, fined, or otherwise acted against?

Yes

Has the owner(s) of the proposed establishment ever held a massage establishment license in Alabama?

Yes

Massage Therapists Employed Step 6 / 14

Do you have any massage therapist(s) employed at this establishment?

Yes

Establishment Attestation Step 7 / 14

Section 34-43-11, Code of Alabama, 1975
1. Establishments shall be licensed by the board. A sexually oriented business may not be licensed as an establishment and shall not operate as an establishment licensed pursuant to this chapter.
2. Establishments shall employ only licensed massage therapists to perform massage therapy.
3. The board shall provide by rule, for a fair and reasonable procedure to grant exemptions from the license requirement of this section when the applicant can show that the advertising of massage therapy services is incidental to the primary function of his or her business. No such exemption shall be granted to a sexually oriented business.
< 4. An establishment license issued pursuant to this chapter is not assignable or transferable.
5. Subsequent to an official complaint, the board may request a criminal background check of the establishment’s licensees through the district attorney of the circuit in which the licensee is located.

I, (we), do certify that I am/We are the person(s) referred to on the application as the owner(s) or legal agent, and that the statements contained herein are true and correct. I understand that it is my/our responsibility to operate this establishment according to the statutes regarding massage therapy and the Rules and Regulations of this Board. I have also read and understand the above requirements.

Signature of Owner(s) or Legal Agent

Date

Attachments Step 8 / 14

Attach a copy of your current business liability insurance policy.

Citizenship Step 9 / 14

PROOF OF CITIZENSHIP
Code of Alabama 1975, Section 31-13-29(g)
From Act 2012-491 1. A driver's license or nondriver's identification card issued by the Alabama Department of Public Safety or the equivalent governmental agency of another state within the United States provided that the governmental agency of another state within the United States requires proof of lawful presence in the United States as a condition of issuance of the driver's license or nondriver*s identification card.
2. A birth certification indicating birth in the United States or one of its territories.
3. Pertinent pages of a United States valid or expired passport identifying the person and the person's passport number, or the person's United States passport.
4. United States naturalization documents on the number of certificate of naturalization. 5. Other documents or methods of proof of United States citizenship issued by the federal government pursuant to the Immigration and Nationality Act of 1952, as amended.
6. Bureau of Indian Affairs card number, tribal treaty card number, or tribal enrollment number.
7. A consular report of birthday abroad of a citizen of the United States of America
8. A certification of citizenship issued by the United States Citizenship and Immigration Services.
9. A certification of report of birth issued by the United States Department of State.
10.An American Indian card, with KIC classification, issued by the United States Department of Homeland Security
11.Final adoption decree showing the person's name and United States birthplace.
12.An official United States military record of service showing the applicant's place of birth in the United States.
13.An extract from a United States hospital record of birth created at the time of the person's birth indicating the place of birth in the United States.
14.AL-Verify.
15.A valid Uniformed Services Privileges and Identification Card.
16.Any other form of identification that the Alabama Department of Revenue Authorizes, through administrative rule promulgated pursuant to the Alabama Administrative Procedure Act, to be used to demonstrate or confirm a person's United States citizenship or lawful presence in the United States, provided that the identification requires proof of lawful presence in the United States as a condition of issuance.

(Must be completed in compliance with Ala. Code § 34-14A-7 and Ala. Code § 41-13-7.)

Are you a citizen of the United States?

Yes

I hereby declare that I am a citizen of the United States of America and, I sign this declaration under penalties of perjury; making a false, fictitious, or fraudulent statement or representation in this declaration is perjury in the second degree pursuant to Ala. Code § 13A-10-102.

Signature of Applicant

Date

If you are not a citizen of the United States, are you an alien who is lawfully present in the United States of America?

Yes

PROVIDE PROOF OF LAWFUL PRESENCE BY SUBMITTING ONE OF THE ITEMS LISTED ABOVE

I hereby declare that I am an alien lawfully present in the United States of America.
I sign this declaration under penalties of perjury; making a false, fictitious, or fraudulent statement or representation in this declaration is perjury in the second degree pursuant to Ala. Code § 13A-10-102.

Signature of Applicant

Date

Background Check Disclosure Step 10 / 14

Alabama Board of Massage Therapy (“the Board”) may obtain information about you from a third party background screening companies for licensing purposes.

These searches will be conducted by Know My Hire, 28577 Hwy. 5 Woodstock, AL | 877.893.5669 | knowmyhire.com

I also understand that iGovSolutions is only a technology provider and the Board is the end-user of the background check.

I acknowledge receipt of the Disclosure Regarding Background Investigation and certify that I have read and understand this disclosure.

Fair Credit Reporting Act(FCRA) Rights tab Step 11 / 14

Please click here to download the Fair Credit Reporting Act (FCRA) .

I acknowledge receipt of the Summary of Your Rights Under the Fair Credit Reporting Act (FCRA) and certify that I have read and understand this document

Notice Regarding Background Investigation tab Step 12 / 14

ACKNOWLEDGMENT AND AUTORIZATION FOR BACKGROUND CHECK
In connection with your application with (The Alabama Board of Massage Therapy) (“Requestor”), notice is hereby given that a consumer report and/or investigative consumer report may be obtained from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or “investigative consumer report” as defined by the Fair Credit Reporting Act (15 U.S.C. § 1681). These reports may contain information about your character, general reputation, personal characteristics and mode of living, whichever are applicable. They may involve personal interviews with sources such as your neighbors, friends or associates. The report may also contain information about you relating to your criminal history, credit history, driving and/or motor vehicle records, social security verification, workers’ compensation claims (after a conditional offer of employment has been made), verification of your education or employment history or other background checks. You have the right, upon written request made within a reasonable time after the receipt of this Notice, to request disclosure of the nature and scope of any investigative consumer report prepared contacting KnowMyHire, 28577 Hwy. 5, Woodstock, AL 35188 – Phone: 877.893.5669. For information about KnowMyHire’s privacy practices see www.KnowMyHire.com. The scope of this Notice and Authorization is not limited to the present and, if you are hired will continue throughout the course of your employment and will allow the Requestor to conduct future screenings for retention, promotion or reassignment, as permitted by law and unless revoked by you in writing. The Requestor also reserves the right to share background investigation results with any third-party companies for whom you will be placed to work as a representative of the Requestor. By e-signing below, I acknowledge receipt of above Notice Regarding Background Investigation and a copy of the federal notice entitled, “A Summary Of Your Rights Under The Fair Credit Reporting Act” and certify that I have read both documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Requestor at any time after receipt of this Authorization and throughout the course of my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer or insurance company to furnish any and all background information requested by KnowMyHire, 28577 Hwy. 5, Woodstock, AL 35188 – Phone: 877.893.5669, www.KnowMyHIre.com, another outside organization acting on behalf of the Requestor, and/or the Requestor. I agree that a facsimile (“fax”), electronic, or photographic copy of this Authorization shall be as valid as an original.

New York applicants only : You have the right to inspect and receive a copy of any investigative consumer report requested by Requestor by contacting KnowMyHire, 28577 Hwy. 5, Woodstock, AL 35188, Phone: 877.893.5669. By e-signing below, you acknowledge receipt of a copy of Article 23-A of the New York Correction Law.

Washington State applicants only : You have the right to request from KnowMyHire a written summary of your rights and remedies under the Washington Fair Credit Reporting Act

Minnesota and Oklahoma applicants only : Please check the box below if you would like to receive a copy of a consumer report if one is obtained by the Requestor.

California applicants only : By e-signing below, you also acknowledge receipt of the “NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW”. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report free of charge, if one is obtained by the Requestor and you have a right to receive such a copy under California Law.

Click here if you’d like Know My Hire to send you a copy of your report.

Review Information Step 13 / 14

Please review Prior to Submission. Corrections can be made by clicking on "PREVIOUS" button at the bottom.

Affirm and Submit Step 14 / 14

E-Signature

Date

Fee

Back Ground Check Fee

Convenience Fee

Total

Person`s Name on Card

Card Number

Card Type

Expiration Date (MM/YY)

Security Code

Billing Zip Code

License #

Name

SSN

License Number

First Name

Last Name

DOB

Home Address Information

Address 1

Address 2

Zip Code

City

State

Home Telephone Number

Establishment Application