Application For License Renewal Form Page 2
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3IF YOU ANSWER “YES” TO ANY QUESTION BELOW, A DETAILED LETTER OF EXPLANATION ALONG
WITH THE DOCUMENTATION INDICATED AFTER EACH QUESTION MUST BE SUBMITTED.
1. Since the last renewal of your license have you been convicted or plead guilty or no contest to
□ Yes
□ No
a felony or any crime, such as fraud, that involves moral turpitude? If so, request a criminal
records check be sent by the appropriate entity directly to the Board.
2. Since the last renewal of your license have you had a license denied, restricted or disciplined by
□ Yes
□ No
any other licensing board or national certifying body? If so, send a request to the
board/body where your disciplinary action occurred for a copy of the decision to be
sent directly to the Board.
3. Since the last renewal of your license have you had any involvement in a civil lawsuit arising out □ Yes
□ No
of or related to your practice of massage and bodywork therapy? If so, send details of the
civil lawsuit to the Board.
4. Do you currently have, or since the last renewal of your license have you had, any mental, emo- □ Yes
□ No
tional, and/or physical disease or condition, including alcohol or other substance abuse, that may
presently interfere with your ability to competently and safely perform the essential functions
involved in the practice of the profession?
5. Since the last renewal of your license have you been addicted to, or used in excess, any drug
□ Yes
□ No
chemical substance, including alcohol, or been treated for a drug or alcohol addiction or partici-
pated in a rehabilitation program?
I hereby affirm that I have read all questions on this renewal application and have answered truthfully, accurately and
completely. I hereby acknowledge that failure to answer these questions truthfully, accurately and completely shall
constitute cause for the initiation of disciplinary action against by North Carolina license. I also affirm that I have read
and comply with the North Carolina Massage and Bodywork Therapy Practice Act and Rules and Regulations of the Board.
Unsigned applications are incomplete and will be returned. In order for this renewal to be considered “on
time” all required forms and fees must be complete and postmarked by November 1. Licenses are not
considered renewed until processed by the Board office.
Signature ______________________________________________________ Date______________________________
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