Massage & Bodywork Licensing Examination Mobility Form Mblex Score Report Request
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2Massage & Bodywork Licensing Examination Mobility Form
MBLEx Score Report Request
MBLEx CANDIDATE INFORMATION
NAME
FIRST
M.I.
LAST
PREVIOUS NAME
(If you took the MBLEx
under a different name)
MM
DD
YYYY
DATE OF BIRTH
SS #
STREET
APT. #
MAILING ADDRESS
CITY
STATE
ZIP
EMAIL ADDRESS
DAYTIME PHONE
SEND MBLEx RESULTS TO
A. STATE LICENSING
BOARD/AGENCY
1.
Attach a separate sheet if
listing more than three States
2.
(not necessary to provide
mailing address for State)
3.
B. OTHER
NAME OF PERSON
NAME OF BUSINESS
STREET
APT # / SUITE
CITY
STATE
ZIP
EMAIL ADDRESS
FEES
TOTAL PAYMENT DUE $20 per Report.
Please provide payment information on the next page. Payment information will be destroyed after processing.
STATEMENT OF ACKNOWLEDGEMENT
I authorize the Federation of State Massage Therapy Boards to provide any and all pertinent information
regarding my Massage & Bodywork Licensing Examination (MBLEx) score(s) to the jurisdiction/state
board/agency/party listed above. I acknowledge and understand that the fee is non-refundable and non-
transferable.
CANDIDATE
DATE
SIGNATURE
Send this MBLEx Mobility Form to:
FSMTB
P.O. Box 198748, Nashville, TN 37219 (U.S. Postal Service)
150 Fourth Avenue North, Suite 800, Nashville, TN 37219 (for courier delivery)
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