Application For License Renewal Form
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2
3NORTH CAROLINA BOARD of
MASSAGE & BODYWORK THERAPY
Mailing Address: PO Box 2539, Raleigh, NC 27602 Phone: 919.546.0050
Location Address: 150 Fayetteville Street, Suite 1900, Raleigh, NC 27601
APPLICATION FOR LICENSE RENEWAL
DO NOT WRITE IN THIS SPACE - FOR OFFICE USE ONLY:
$
Check Amount: _
____________
Received On:_____________________
Processed By:______________
Check Number:_______________
Returned On:____________________
Approved By:_______________
Applications for License Renewal must be typed or printed in ink and submitted with a $100.00 non-refundable money order or check
made payable to NCBMBT. Incomplete or partial applications will be returned. Applications for License Renewal are only accepted
st
st
st
between August 1
and November 1
of your designated renewal year. Applications for License Renewal received before August 1
st
will be returned.
Applications postmarked after November 1
will incur a $75.00 late fee and a Letter of Reprimand will be issued
for late renewal.
North Carolina License Number:
___
□
□
Is this your first renewal and have you been licensed less than two years?
Yes
No
PERSONAL INFORMATION:
Last Name:__________________________First:_________________Middle:____________Maiden:__________________
Mailing Address:__________________________________________County of Residence:__________________________
City:_______________________________________________________________State:_____________Zip:___________
Home Phone: (_____)_________________Social Security #:____________ ___________ Date of Birth:___ __________
Cell Phone:
(_____)________________ Email Address:_______________________________
________________
DOES THIS REFLECT:
□
□
Name Change?
Yes
No -
If your answ er is “yes”, a photocopy of the court docum ent relating to a m arriage,
divorce or name change must be subm itted or the nam e cannot be changed.
□
□
Address Change?
Yes
No -
If you answ ered "yes" to address change, list previous address below :
Address:_____________________________________City:_____________________State:___________Zip:_________
EMPLOYMENT:
Place of Employment:_______________________________________________________________________________
Mailing Address:__________________________________________County of Business:__________________________
City:_______________________________State:____________Zip:____________Work Phone: (____ )______________
(over)
Revised 10.2014
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