:: Initial Applications ::

Massage Therapy Instructor

Instructions Step 1 / 9

Fee Schedule

Application Fee: $10

To qualify as an approved licensed massage therapy instructor,
1. Attach a copy of your current Alabama Massage Therapy License Certificate
2. Please refer to Section 34-43-20(5), Code of Alabama, 1975, to familiarize yourself with the requirements for registration as a massage therapy school instructor.
3.Document two years of experience in the practice of massage therapy, which documentation may include:

a. City business licenses showing the occupation as a massage therapist;

b. Internal Revenue Service tax returns listing the occupation as massage therapist;

c. Records or correspondence regarding advertisement as a massage therapist;

d. Affiliations with professional organizations;

e. Appointment books kept in the ordinary course of business;

f. Statements from personal knowledge by persons not related to the applicant, which may include: notarized statements of clients; statements of licensed professional associates consulted in relation to the practice of massage therapy; statements of business 16 associates consulted in relation to the practice of massage therapy, such as bankers, brokers, attorneys.

Screen Guide Step 2 / 9

Screen Layout

Reviewing Completed Application

Printing Application

Applicant Information Step 3 / 9

Last Name

First Name

Middle Name

Social Security Number

Date of Birth

Mailing Address Information

Address 1

Address 2

Zip Code

City

State

Contact Information

Phone Number

Email Address

Instructor Information Step 4 / 9

Name of Primary School (where you will be instructing)

How long have you been an instructor at the above school

Alabama License #

Original Issue Date

Expiration Date

^*Your license must be Active in order to apply

Attachments Step 5 / 9

Attach a copy of your current Alabama Massage Therapy License Certificate

Attach a notarized letter documenting two years of current massage therapy experience

Applicant Attestation Step 6 / 9

I certify that I am the person referred to on the application and that the statements contained herein are true and correct. I understand that it is my responsibility to operate as a massage therapy instructor according to the statutes regarding massage therapy and the Rules and Regulations of this Board.

Signature

Date

Citizenship Step 7 / 9

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

Review Information Step 8 / 9

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

Affirm and Submit Step 9 / 9

E-Signature

Date

Fee

Convenience Fee

Total

Person`s Name on Card

Card Number

Card Type

Expiration Date (MM/YY)

Security Code

Billing Zip Code