Massage Therapist Form 5 - Application For Limited Permit Page 2
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Employers Name: ________________________________________________________________________________________________________
10
Affidavit: I declare and affirm that the statements made in the foregoing application are true, complete and correct. Any false or misleading information
in, or in connection with, my application may be cause for denial of permit and licensure and may result in criminal prosecution.
_______________________________________________________________________________________
_______ / _______ / _______
Applicant’s signature
mo.
day
yr.
NOTICE TO APPLICANTS FOR LIMITED PERMIT AUTHORIZING THE PRACTICE OF MASSAGE THERAPY
78.3 Limited Permits. The Department may issue a limited permit in massage therapy as provided in section 7806 of the Education Law to
applicants who are eligible for the licensing examination and who have not previously failed such examination.
(a) The limited permit is valid for no more than 12 months or until the results of the next licensing examination for which the applicant is eligible are
officially available. It is not renewable.
(b) Personal supervision, as used in section 7806(3) of the Education Law, shall mean that a supervising massage therapist shall be present on the
premises at all times when professional services are being rendered by the holder of the limited permit, and shall exercise that degree of
supervision appropriate to the circumstances.
SECTION II: CERTIFICATION OF SUPERVISING MASSAGE THERAPIST
INSTRUCTIONS TO THE SUPERVISOR
1.
Complete this section and be sure to sign and date the attestation. The supervisor is certifying that the permittee named in Section I will
practice under the supervision of a New York State licensed, currently registered massage therapist.
2.
The applicant may not practice until the limited permit is issued.
3.
The limited permit cannot be issued until the applicant’s education has been approved, and shall expire one year from the date of
issuance or until notification of the results of the next licensing examination for which the applicant is eligible. It is not renewable.
1.
Name of supervising massage therapist: _______________________________________________________________________
2.
License number: __________________________________
3.
Office address: ________________________________________________________________________________________________
Street
City
State
Zip code
4.
Telephone number: (_________) _________________________________ Fax: _________________________________________
E-mail: ______________________________________________________
5.
Is this the only location in which the permittee will practice?
YES
NO
If no, please indicate additional practice sites:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
6.
Are there any other massage therapy permittees working under your supervision?
YES
NO
If so, how many? _____________________________
What are their names? __________________________________________________________________________________________
_____________________________________________________________________________________________________________
ATTESTATION
I declare and affirm that the statements made in the foregoing certification are true, complete and correct. Any false or misleading information
in or in connection with this certification may be cause for denial of permit and licensure and may result in criminal prosecution.
_______________________________________________________________________
______________________________________
Signature
Date
_______________________________________________________________________________________________________________
Title
_______________________________________________________________________________________________________________
Print name
New York State Education Department, Office of the Professions, PO Box 22063, Albany, NY 12201.
RETURN DIRECTLY TO:
Massage Therapist Form 5, Page 2 of 2, Rev. 6/16
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