Application For License Renewal/reinstatement

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Division of Occupational & Professional Licensing

APPLICATION FOR LICENSE RENEWAL / REINSTATEMENT

P.O. Box 146741, Salt Lake City, Utah 84114-6741

INTERNET RENEWAL

LICENSE NUMBER

OCCUPATION / PROFESSION TITLE

RENEWAL FEE

EXPIRATION DATE

REINSTATEMENTS

ID NUMBER

Please fill in:

Please call DOPL for

Additional fees are required

Massage Therapist

$52.00

05/31/2011

your Internet

after expiration. See

Renewal ID Number

reverse for details.

↓ ↓ ↓ ↓ NAME AND ADDRESS OF RECORD ↓ ↓ ↓ ↓

↓ ↓ ↓ ↓ ADDRESS / PHONE CORRECTION ↓ ↓ ↓ ↓

Address:

City:

Phone: (

)

Email:

This address will be used for all correspondence from DOPL. You may

use a business address or PO Box instead of a home address. If your

address changes, notify DOPL directly. Do not rely on a postal service

forwarding order. Submit changes at

Please write in your name and address of record.

QUALIFYING QUESTIONNAIRE

Answer “YES” or “NO” for each question. Do not leave any question blank.

Please note that false, misleading, or fraudulent answers may result in loss of licensure and/or criminal prosecution and are subject to random audit.

(For questions 1 - 4 below, motor vehicle offenses such as driving while impaired or intoxicated must be disclosed, but minor traffic offenses such as parking or speeding violations do

not need to be listed.)

1. Since the last renewal or issuance of this license have you pled guilty to, pled no contest to, been convicted of, made a

Yes

plea in abeyance to, or entered into a deferred sentence with respect to any felony or misdemeanor in any jurisdiction?

2. Since the last renewal or issuance of this license have you been charged with or arrested for any felony or misdemeanor

Yes

in any jurisdiction?

3. Since the last renewal or issuance of this license have you surrendered or had any disciplinary action taken against a

Yes

license to practice in a regulated profession?

4. Are you currently under investigation or is any disciplinary, administrative, or criminal action pending against you now by

Yes

any agency?

If you answered “YES” to question 1, 2, 3 or 4 above, see #1A on page two for instructions on additional requirements.

AFFIDAVIT / SIGNATURE

Read the following carefully. Sign below or follow the instructions as indicated.

I certify under penalty of perjury that I am a United States citizen or a qualified alien who is lawfully able to work in the United States.

I also certify that I have completed or will complete all renewal requirements, if applicable, including those specified below before the

expiration or reinstatement of my license. I understand that I may be subject to audit by DOPL of having met these requirements.

I further certify that I am the licensee described and identified in this application for license renewal / reinstatement. I am qualified in all

respects for the renewal or reinstatement of this license. To the best of my knowledge, the information contained in this application is

complete and correct, and is free of fraud, misrepresentation, or omission of material fact. I understand that this application will be

classified as a public record and will be available for inspection by the public, except with regard to the release of information which is

classified as controlled, private, or protected under the Government Records Access and Management Act or restricted by other law.

I am a citizen of the United States.

I am a qualified alien as defined in 8 U.S.C., Sec 1641 who is lawfully present in the United States. I understand that I am

required to visit DOPL’s offices and present a government issued ID bearing my photo and evidence of one, or both of the

following:

Alien ID Number ________________

I-94 Number ____________________

I am a foreign national not physically present in the United States.

(If you check this item you do not need to respond to the following

and

section.)

I have a valid Driver License or State Issued ID State: _____ Number: ______________

I do not have a Driver License. I am legally present in the United States, and I understand that the Department of Commerce will

verify my legal presence in order to process my renewal/reinstatement.

Social Security Number ____-___-_____

Signature: __________________________________________ Date: ____/____/______

(If unable to sign, see #1B on page 2 for instructions.)

Unlawful Conduct: Your license will automatically

RENEWAL REQUIREMENTS

Specific to your occupation / profession:

expire unless you renew it prior to its expiration date. If

your license expires, you may not practice until a new

license is issued. Subsection 58-1-501(1)(a) and

Section 58-1-502, U.C.A., make it unlawful and

punishable as a criminal offense to practice your

occupation or profession beyond the expiration of your

license.

For Division Use Only – Do Not Write in this Area

Application For License Renewal/reinstatement - Utah

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