Massage Therapist Form 5 - Application For Limited Permit
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1
2The University of the State of New York
Department Use Only
Massage Therapist Form 5
THE STATE EDUCATION DEPARTMENT
Office of the Professions
Division of Professional Licensing Services
Application for Limited Permit
APPLICANT INSTRUCTIONS
You may not engage in private practice if you hold a limited permit. You must be employed by a licensed massage
therapist or by an entity authorized to practice massage therapy that engages a licensed massage therapist to provide
personal, on-site supervision.
1.
You may file an application for a limited permit with or after submitting an Application for Licensure (Form
1) and fee as a massage therapist in New York State to practice pending receipt of the license.
1
27
$35
PR
2.
Complete Section I in ink. Be sure to sign and date item 10 on page 2. Note: Once limited permits are issued, they
may not be adjusted. You should be certain you are ready to begin practice when you apply for the limited permit.
NYS Permit Number
Forward to your supervisor to complete Section II.
3.
Submit the completed application and a $35 fee to the address at the end of this form. If you have not yet filed an
Application for Licensure (Form 1) and the $108 fee, you must submit them with this form and the limited
permit fee. Your permit cannot be issued until we receive and approve all required documentation. You may not
Date Issued
begin practice until your limited permit is issued.
4.
If you change employment after a permit is issued, you must obtain a new permit and, with each prospective
employer, complete a new form 5 and return it to the Office of the Professions. A new fee is not required for a
Date Expires
permit issued as a result of a change in employment. The original permit must be signed/dated on the back and
returned to the Department.
SECTION I: APPLICANT INFORMATION
6
Telephone/E-Mail Address
2
Social Security Number
(Leave this blank if you do not have a U.S. Social Security Number)
Daytime Phone
3
Month
Birth Date
Day
Year
Phone Number
Area Code
4
Print Your Name Exactly As It Appears On Your Licensure Application (Form 1)
E-Mail Address (Please print clearly)
Last
First
Middle
5
Mailing Address (You must notify the Department promptly of any address or name changes.)
7
I am applying for:
Line 1
Additional supervisor/site
Line 2
New supervisor/site
Line 3
City
State
Zip Code
Country/
Province
8
CITIZENSHIP/IMMIGRATION STATUS:
Federal law and the Regulations of the Commissioner of Education (8 NYCRR §59.4) limit the issuance of professional licenses, registrations
and limited permits to United States citizens or qualified aliens. To comply with Federal law and Commissioner’s regulation, you must complete
this section of this form and check the appropriate box below which indicates your citizenship/immigration status.
I am:
A.
A United States citizen or National.
B.
An alien lawfully admitted for permanent residence in the United States.
C.
An alien granted asylum under Section 208 of the Immigration and Nationality Act.
D.
A refugee granted asylum under Section 207 of the Immigration and Nationality Act.
E.
An alien paroled into the United States under Section 212 (d)(5) of the Immigration and Nationality Act for a period of at least 1 year.
F.
An alien whose deportation is being withheld under Section 241 (b)(3) of the Immigration and Nationality Act.
G.
An alien granted conditional entry pursuant to Section 203 (a)(7) of the Immigration and Nationality Act as in effect prior to April 1980.
H.
Non Immigrant (Temporarily in U.S.) Please list Visa type or immigration status or attach a copy of your passport if you are not required to
have a Visa to enter the United States: _______________________________________
I.
I am an alien not unlawfully present in the United States pursuant to the Deferred Action for Childhood Arrivals (DACA) relief or similar
relief from deportation. Please specify: _______________________________________
J.
I do not reside in the United States.
If you checked any of the boxes from B-I, enter your alien registration number or control number issued by the United States Citizenship and
Immigration Services (USCIS):
USCIS number: ___________________________________________
QUESTIONS ABOUT YOUR IMMIGRATION STATUS AND WHETHER OR NOT IT IS A QUALIFYING STATUS UNDER FEDERAL LAW SHOULD
BE DIRECTED TO THE U.S. CITIZENSHIP AND IMMIGRATION SERVICES (USCIS) BY CALLING 1-800-375-5283, OR VISIT THEIR WEB SITE
AT
Massage Therapist Form 5, Page 1 of 2, Rev. 6/16
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