Florida Board Of Massage Therapy License Verification Request printable pdf download

Florida Board Of Massage Therapy License Verification Request

FLORIDA BOARD OF MASSAGE THERAPY LICENSE VERIFICATION REQUEST

PART I: TO BE COMPLETED BY APPLICANT

Send to all state(s) of licensure (not Florida). Make Copies as necessary

Applicant Name: __________________________________________ SSN: ____________________

Address: __________________________________________________________________________

Name original license was issued under: _________________________________________________

License Number: ___________________________ State: _________________________________

I hereby authorize release of any information regarding my licensure status to the Florida Board of Massage

Therapy.

Applicant Signature: ________________________________________ Date: __________________

PART II: All verifications shall be completed in English and mailed or sent electronically directly from the

state(s) or jurisdiction(s) and must include the following criteria:

* Typed on an official state form or letterhead

* Include an official Board seal

* Signature and title of state Board official

The following information must be included in all verifications:

* Licensee name

* License number

* State or jurisdiction of licensure

* Dates of issuance/expiration

* Licensure method; exam type or endorsement

* Licensure status

* Is license in good standing?

* Has this license ever been encumbered (denied, revoked, suspended surrendered, limited, placed on probation)?

Complete Verifications must be mailed to or sent electronically directly from the official state licensure

Board to:

Florida Board of Massage Therapy

4052 Bald Cypress Way

Bin C06

Tallahassee, FL 32399-3256

Fax (850) 412-2681

MQA.MassageTherapy@flhealth.gov

Rules 29.002 and 29.007

DH-MQA 1265, 11/12

Florida Board Of Massage Therapy License Verification Request