:: Initial Applications ::

Instructions Step 1 / 15

Fee Schedule

Application Fee: $50
The annual renewal fee is $10.00.
Please note that if a change in curriculum, ownership or faculty occurs, you must submit the new information in writing within 30 days to the Board’s office.

To qualify as an approved licensed massage therapy school, All items listed below must be completed and submitted with your application

1. Sample transcript and sample diploma.
2. Send a copy of the curriculum schedule for massage therapy to include a week-by-week description of topics to be covered for the entire training period of each program.
3. List instructional material and equipment to be used, such as: test materials, supplemental teaching devices, audio visual aids, major items of demonstration, and practice equipment.
4. Methods that are or will be used to keep subject matter updated.
5. Submit faculty credentials and include instructors.
6. Include a copy of your published policy regarding performance level required before students can graduate.
7. Send copies of your enrollment contract. Your enrollment contract is the contract that you have with anyone who is enrolled in your school.
8. Submit training objectives of each program offered by the school.
9. Syllabus for each course.
10.Please list all the credentials a student may be awarded.
11. A copy of your catalogue.

Screen Guide Step 2 / 15

Screen Layout

Reviewing Completed Application

Printing Application

Institution Information Step 3 / 15

Official Name of Institution

Business Name

Mailing Address Information

Address 1

Address 2

Zip Code

City

State

Physical Address Information (if not same as mailing)

Same as mailing address

Address 1

Address 2

Zip Code

City

State

Contact Information

Phone#

Alternate Phone#

Fax#

Owner Information Step 4 / 15

Enter one or more Owner of school

Legal Questions Step 5 / 15

Has your institution had any civil or government initiated investigations, complaints or legal action during the past 5 years?

Yes

What other legal action has occurred during the past 5 years of a material nature regarding your massage therapy education or status?

Yes

Any legal action pending? Please give a full description.

Yes

Training Programs Step 6 / 15

Enter list of all training programs for your staff

Ownership Types Step 7 / 15

Instructors Step 8 / 15

Enter list of all instructors below:

No instructors

Administrative Officers Step 9 / 15

Enter Administrative Officers

Chief Academic Officer Step 10 / 15

Chief Academic Officer of Institute

Last Name

First Name

Title

Mailing Address Information

Address 1

Address 2

Zip Code

City

State

Phone

Authorized Agent Step 11 / 15

Authorized Agent

Last Name

First Name

Title

Mailing Address Information

Address 1

Address 2

Zip Code

City

State

Phone

Attachments Step 12 / 15

Please attach sample transcript and sample diploma.

Attach a copy of the curriculum schedule for massage therapy to include a week-by-week description of topics to be covered for the entire training period of each program.

Attach list of instructional material and equipment to be used, such as: test materials, supplemental teaching devices, audio visual aids, major items of demonstration, and practice equipment.

Methods that are or will be used to keep subject matter updated

Attach a copy of your published policy regarding performance level required before students can graduate.

Attach copies of your enrollment contract. Your enrollment contract is the contract that you have with anyone who is enrolled in your school.

Submit training objectives of each program offered by the school.

Syllabus for each course

Attach a list of all the credentials a student may be awarded.

A copy of your catalogue.

Citizenship Step 13 / 15

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 14 / 15

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

Affirm and Submit Step 15 / 15

E-Signature of School Admin. or School Officer

SSN of School Admin. or School Officer

Date

Fee

Convenience Fee

Total

Person`s Name on Card

Card Number

Card Type

Expiration Date (MM/YY)

Security Code

Billing Zip Code

Instructor License #

Instructor Name

Program Title

Total Hours

Number of Weeks Required for Completion

First Name

Last Name

Title

Address1

Address2

Zip

City

State

Phone

SSN

License Number

First Name

Last Name

DOB

Home Address Information

Address 1

Address 2

Zip Code

City

State

Home Telephone Number

School Application