Ncbtmb Verification Of Education Form

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This form may be used in lieu of an official transcript, if the education/training institution does not issue transcripts, or as a supplement to an official transcript, if the

transcript does not provide information regarding the number of hours in a particular course. Verification must be signed by the School President or Program Director.

Name of Candidate: _______________________________________________________________________

SCHOOL

(1) Name: _______________________________________________________________________________

(2) Address: ______________________________________________________________________________

(Please attach grade sheets, mark sheets or other record showing courses completed by year and grades)

(3) Length of Program: ____________________________________________________________________

(4) Data of Admission: __________________________ Date of Completion: ________________________

Date of Graduation: _________________________ Credential Award: __________________________

(5) Program is accredited or recognized by: ___________________________________________________

(6) List the hours spent in instruction in each of the following subjects:

Subject

Hours of Instruction

Human Anatomy/Physiology, Kinesiology

(To include all 11 systems of the human body)

Clinical Pathology and recognition of various conditions

Massage/bodywork theory, assessment and practice*

(Must be in-class, instructor supervised coursework)

Adjunct techniques and methods

Business practices and professionalism

(Minimum 6 clock hours of ethics required)

Other:

TOTAL Hours

)

(To include above and any additional hours required for graduation

Verification must be signed by the school President or Program Director and must include the official seal or

stamp of the school.

I hereby certify that to the best of my knowledge and belief the foregoing is a true statement

of the record of the individual named on this form. NCBTMB reserves the right to request

additional documentation or further evidence of academic accomplishments.

Signature: ______________________________________________________________________

Print Name: ______________________________________________________________________

Title: __________________________________________Date: ____________________________

Phone:_________________________________________

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Version 12.1