Massage Therapy Form 3 - Verification Of Out-Of-State Licensure Or Registration - New York The State Education Department

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Massage Therapist Form 3
The University of the State of New York
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
89 Washington Avenue
Albany, NY 12234-1000
VERIFICATION OF OUT-OF-STATE
LICENSURE OR REGISTRATION
APPLICANT INSTRUCTIONS
Use this form only if you have or ever held a license or registration to practice as a massage therapist in another state, province or country.
1.
Complete Section 1 in ink. Enter your name as it appears on your Licensure Application (Form 1) and be sure to sign and date item 7.
2.
Send this form to the jurisdictions in which you are licensed. Be sure to include any fee required by that licensing authority. The licensing authority
must forward this form directly to the Office of the Professions at the address at the end of this form.
SECTION I: APPLICANT INFORMATION
1
2
Birth Date
Social Security Number
Month
Day
Year
(Leave this blank if you do not have a U.S. Social Security Number)
3
Print Name Exactly As It Appears On Your Licensure Application (Form 1)
Last
First
Middle
Mailing Address
(
You must notify the Department promptly of any name or address changes.)
4
Line 1
Line 2
Line 3
City
State
Zip Code
Country/
Province
5
Print your name below as it appears on your license from another jurisdiction (if different from above):
6
Jurisdiction in which you are licensed: ___________________________________________ License number:________________________
7
I request and give my permission to the licensing authority to complete the information on this form and send any documentation
requested, including that listed on page 2 of this form, to the New York State Education Department.
Applicant's signature:
Date:
/
/
____________________________________________________________________
_______
_______
_______
mo.
day
yr.
Massage Therapist Form 3, Page 1 of 2, (REV. 07/04)

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