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GEORGIA BOARD OF MASSAGE THERAPY237 Coliseum Drive * Macon, Georgia 31217-3858(404) 424-9966 * PLICATION FOR REINSTATEMENT OF LICENSE*REINSTATEMENT IS AT THE DISCRETION OF THE BOARD*Application Fee: 210.00 – ( 200.00 application fee 10.00 processing fee)Non-Refundable & Non-TransferableChecks returned for insufficient funds w ill be assessed a 4 0.0 0 service charge pursuant to O.C.G.A. § 16 -9-20).SECTION I: PERSONAL INFORMATIONNAMELastFirstMiddle(Maiden)NAME (in which license was originally issued if different):LastFirstMiddle(Maiden)*SOCIAL SECURITY # - - DATE OF BIRTH MM-DD-YYY(*THIS INFORMATION IS AUTHORIZED TO BE OBTAINED AND DISCLOSED TO STATE AND FEDERAL AGENCIES PURSUANT TO O.C.G.A. §§ 1911-1 & 20-3-295, U.S.C.A §§ 551, 20 & 1001)PHYSICAL ADDRESSHOME ADDRESS (P.O. BOX, NOT ACCEPTABLE)CITYAPT #STATE ZIPYour name, mailing address and license number are public information and your mailing address only will appear on the internet. Your physical address isrequired, if different than the mailing address. You must immediately notify the Board in writing of an address change.MAILING ADDRESSMAILING ADDRESS (IF DIFFERENT THAN HOME ADDRESS – P.O. Box is acceptable)APT#CITYSTATEDAYTIME PHONE()ZIPOTHER PHONE (E-MAIL ADDRESS:Male)FemaleAcknowledgement of your application will be sent by e-mail. Also, if any additional information is needed, e-mail is the most efficient way forthe Board staff to contact you so that your application can be processed in the most efficient manner. Please notify the Board of any e-mailaddress change. YOUR E-MAIL ADDRESS WILL NOT BE SHARED WITH ANY THIRD PARTY. Please check this box if you are a military spouse or a transitioning service member of the United StatesArmed Forces (including the National Guard) as defined in O.C.G.A. § 43-1-34.I hereby apply to reinstate my Massage Therapy license MTDate expired://. ReasonLicense #; Date issued//;license was not renewed:Have you completed the required Continuing Education hours? ( ) Yes ( ) No (Verification is required for0Page 3 of 12Rev. 3/11/22Y

reinstatement consideration; attach copies of certificates, course outlines/agenda for the hours obtained within one (1) year ofthe date of this reinstatement application).SECTION II: PROFESSIONAL INFORMATIONDo you hold a license to practice as a Massage Therapist in another state? ( ) Yes ( ) No(If no, continue to the next question. If yes, please provide the following information, and contact each State Boardto request certified/official verification of your license and its current status. The certified verification must be sentdirectly from the primary source to: Georgia Massage Therapy Board, 237 Coliseum Drive, Macon, Georgia 31217-3858,or if in a PDF format electronically to [email protected]:License #:Expiration Date:State:License #:Expiration Date:State:License #:Expiration Date:List any other license or certificate you hold or may have held in another profession:State:Type:License #:Expiration Date:State:Type:License #:Expiration Date:State:Type:License #:Expiration Date:*Note: The Board does not require a verification of license/certification (other than a massage therapist) from theabove list. You may provide copies of your licensure card or certificate if you choose to do so. However, if you havehad ANY disciplinary action taken against ANY of the above listed license/certification, including those in massage,you must provide the Board with a copy of the official document which provides the final disposition of the action(s)taken.SECTION III: EDUCATION/EXAMINATION INFORMATIONNAME, CITY AND STATE OF YOUR MASSAGE THERAPY EDUCATION PROGRAM:Date of graduation:Certification or Diploma:WHAT CITY AND STATE DID YOU ATTEND HIGH SCHOOL?NAME OF HIGH SCHOOLDid you graduate?YESNOGive the date of graduationCircle how many years were completed.If you did not graduate from high school, do you have a GEDOr other high school equivalency certificate?YESNO12345Give the date of graduation* NOTE: A copy of H igh School Diploma, GED or Certificate may be requested as evidence of completion.Have you taken and passed either the National Certification Board of Therapeutic Massage and Bodywork(NCBTMB) NCETM, NCETMB or NESL exam, or, the Federation of State Massage Therapy Boards (FSMTB)MBLEx exam? ( ) Yes ( ) NoIf yes, indicate which exam and date passed:ExaminationDate PassedIf no, please indicate reason for not taking/passing one of the Board approved examinations:(Some applicants for reinstatement may be required to take and pass one of the recognized exams before licensurereinstatement is considered/granted by the Board)Were you originally licensed as a Massage Therapist in Georgia under the “Grandfathering In” provisions0Page 4 of 12Rev. 3/11/22

effective for applications received on or beforeJune 30, 2007?( ) Yes ( ) NoSECTION IV: MASSAGE THERAPY PRACTICE/EMPLOYMENTHave you practiced as a Massage Therapist in Georgia, or any other state, since your license expired?( ) Yes ( ) No * If yes, list below the dates of employment, name of employer or agency, and job title.When did you last practice as a Massage Therapist:/Month/Day/Year/(Provide your last three places of employment; list the most recent employer first):MT Practice(yes or no)YESNOYESNOYESNOPlace of practice: Name of Employer orAgency, city and state:Job TitleDates of Employment:* NOTE: Submit the Verification of Employment form (page 7) to your most recent Employer to verify practice/employment as apaid Massage Therapist. Section II of the Verification of Employment form must be completed and signed by your employer.The form will not be accepted if completed by the applicant. The form may be submitted with your application or maileddirectly to the Board by the employer, but MUST not be completed/filled out by the applicant.**If self-employed, complete the Verification of Employment form yourself, indicate self-employed, and sign it.SECTION V: BACKGROUND INFORMATIONIf you answer “yes” to any of the following questions, you are required to provide a written explanation of the action or incident.For the first question, if you answer ‘yes”, you must submit a certified copy of the official document (indictments, court orders,police records, certified warrants, court dismissals, verdicts or first offender treatment, etc) which indicate the final dispositionof any reported event or incident. For next two questions, if you answered “yes”, provide a detailed letter of explanation and acopy of any Board or regulatory authority’s order or action of the Board or authority. You are expected to read each questioncarefully and completely. In addition, you are to notify the Board of any future events as described below. You will be asked tocertify under oath that the answers are true and correct. Failure to answer these questions truthfully may constitute grounds forthe denial your application, Failure to notify the Board of any future incidents may constitute grounds for disciplinary actions.1) HAVE YOU EVER BEEN ARRESTED, CONVICTED, SENTENCED, PLED GUILTY, OR NOLO CONTENDERE ORBEEN GIVEN FIRST OFFENDER STATUS FOR ANY FELONY, MISDEMEANOR OR ANY OFFENSE OTHERTHAN A MINOR TRAFFIC VIOLATION? (DWI AND DUI or any traffic incident resulting in an arrest warrant, arrest orjail time is not a minor traffic violation. For purposes of this question; “felony” includes any offenses which, if committedin this state, would be deemed a felony and a “conviction” includes a finding or verdict of guilty, or a plea of nolocontendere, in a criminal proceeding regardless of whether an appeal of the conviction has been sought, and, also includesany adjudication of guilt or sentence withheld or not entered pursuant to the provisions of Code Sections §§42-08-64,relating to first offenders, or any comparable rule or statue. (Note: You must respond, “yes” if you pled and completed probation( ) Yes ( ) Noas a First Offender.)2) Has any other licensing Board or other regulatory Agency in Georgia or any other state:a. Denied your license application, renewal or reinstatement?b. Reprimanded, suspended, revoked, fined, restricted, placed you on probation, requestedor accepted the voluntary surrender of your license?3) In the past have you:a. Failed or been refused an examination by any professional organization, Board or otherregulatory entity?b. Had professional liability suits filed against you?c. Used drugs or other intoxicating substances to the extent that these affected yourprofessional competence?d. Been reprimanded, demoted, disciplined, terminated, or cautioned by an employer?0Page 5 of 12Rev. 3/11/22( ) Yes ( ) No( ) Yes ( ) No( ) Yes ( ) No( ) Yes ( ) No( ) Yes ( ) No( ) Yes ( ) No

SECTION VI: APPLICANT SIGNATURE AND AFFIDAVITYOU MUST SIGN THIS AFFIDAVIT IN THE PRESENCE OF A NOTARYI hereby swear and affirm that all information provided in this application is true and correct to the best of myknowledge and belief. I further swear and affirm that I have read and understand the current state laws and rulesand regulations of the Georgia State Board of Massage Therapy, and I agree to abide by these laws and rules, asamended from time to time.By signing this application, electronically or otherwise, I hereby swear and affirm one of the following to be trueand accurate pursuant to O.C.G.A. § 50-36-1:1)I am a United States citizen 18 years of age or older. Please submit a copy of your currentSecure and Verifiable Document(s) such as driver’s license, passport, or other document asindicated on pages 8 & 9 of this application.2)I am not a United States citizen, but I am a legal permanent resident of the United States 18 years ofage or older, or I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act 18years of age or older with an alien number issued by the Department of Homeland Security or other federalimmigration agency. Please submit a copy of your current immigration document(s) which includes eitheryour Alien number or your I-94 number and, if needed, SEVIS number (See pages 8 & 9 of thisapplication).In making the above attestation, I understand that any failure to make full and accurate disclosures may result indisciplinary action by the Georgia State Board of Massage Therapy and/or criminal prosecution.Signature of ApplicantDateSworn to and subscribed before me thisday of, 20Notary Public Signature(Notary Seal)My commission expires:Note to Notary: Application should be signed with proper ID.0Page 6 of 12Rev. 3/11/22

PLEASE SEPARATE THIS FORM, GIVE TO YOUR MOST RECENT EMPLOYER TO COMPLETE, ANDRETURN THE COMPLETED, SIGNED AND NOTARIZED FORM TO THE BOARD:GEORGIA BOARD OF MASSAGE THERAPY237 COLISEUM DRIVE, MACON, GEORGIA 31217-3858VERIFICATION OF EMPLOYMENTInstructions:1. Applicant: complete Section I and sign.2. Submit this form to your most recent employer (Personnel Director, Human Resources Department) who can provideverification of your practice as a massage therapist.3. If you are self-employed, complete the Verification of Employment form yourself, indicate self-employed, and sign it.4. Return the completed, signed and notarized form with your application materials to the Board.Section I (to be completed by applicant)Printed Name of Applicant:LastFirstMiddleMaidenApplicants Address:StreetCityStateZip CodeRELEASE: I do hereby consent to and authorize the release of any and all records and information concerning my employment as aMassage Therapist to the Georgia Board of Massage Therapy. I understand this information is required as part of the application forlicensure process.APPLICANTS SIGNATUREPHONE NUMBER(S)APPLICANT – DO NOT WRITE BELOW THIS LINE:(If Self-Employed, complete this section for your business)Section II (to be completed by person verifying employment)Instructions:1. Complete Section II of this form. If self-employed, complete this section indicating your business name, address, etc .2. Massage Therapy employment must have been for compensation.3. Return this form to the applicant to submit with their application for licensure.1. Name of Business:Phone Number:2. Physical Address of Employer:(City/State/Zip Code)3. Applicant’s Position/Title:4. Employment Dates: From:To:5. Physical Location of practice (mobile, contract, or same as above):6. Printed name and title of person verifying employment:(Name)(Title)Signature of Employer/Person completing this formSworn to and subscribed before me thisday of, 20(Notary Public Signature)My commission expires:0Page 7 of 12(Notary Seal)Rev. 3/11/22

APPLICANT: PLEASE CHECK THE FORM OF IDENTIFICATION BELOW THAT YOUPOSSESS. RETURN THIS FORM ALONG WITH A COPY OF YOUR APPROPRIATEDOCUMENTATION.(Printed Name of Applicant)Secure and Verifiable Documents Under O.C.G.A. § 50-36-2Issued October 28, 2016, by the Office of the Attorney General, GeorgiaThe Illegal Immigration Reform and Enforcement Act of 2011 (“IIREA”), as amended by Senate Bill 160, signed intolaw as Act No. 27, (2013), provides that “[n]ot later than August 1, 2011, the Attorney General shall provide and makepublic on the Department of Law’s website a list of acceptable secure and verifiable documents. The list shall bereviewed and updated annually by the Attorney General.” O.C.G.A. § 50-36-2(g). The Attorney General may modifythis list on a more frequent basis, if necessary.The following list of secure and verifiable documents, published under the authority of O.C.G.A. § 50-36-2, containsdocuments that are verifiable for identification purposes, and documents on this list may not necessarily be indicative ofresidency or immigration status.An unexpired United States passport or passport card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]An unexpired United States military identification card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]An unexpired driver’s license issued by one of the United States, the District of Columbia, the Commonwealthof Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Island,American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficientidentifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address toenable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]1An unexpired identification card issued by one of the United States, the District of Columbia, theCommonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States VirginIsland, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficientidentifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address toenable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]An unexpired tribal identification card of a federally recognized Native American tribe, provided that it containsa photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth,gender, height, eye color, and address to enable the identification of the bearer. A listing of federally recognizedNative American tribes may be found nmentServices/TribalDirectory/ind ex.htm [O.C.G.A. § 50-362(b)(3); 8 CFR § 274a.2]An unexpired United States Permanent Resident Card or Alien Registration Receipt Card [O.C.G.A. § 50-362(b)(3); 8 CFR § 274a.2]An unexpired Employment Authorization Document that contains a photograph of the bearer [O.C.G.A. § 5036- 2(b)(3); 8 CFR § 274a.2]A unexpired passport issued by a foreign government, provided that such passport is accompanied by a UnitedStates Department of Homeland Security (DHS") Form I-94, DHS Form I-94A, DHS Form I-94W, or other federalform specifying an individual's lawful immigration status or other proof of lawful presence under federal immigrationlaw2 [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]An unexpired Merchant Mariner Document or Merchant Mariner Credential issued by the United States Coast0Page 8 of 12Rev. 3/11/22

Guard [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]An unexpired Free and Secure Trade (FAST) card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]An unexpired NEXUS card [O.C.G.A. § 50-36-2(b)(3); 22 CFR § 41.2]An unexpired Secure Electronic Network for Travelers Rapid Inspection (SENTRI) card [O.C.G.A.§50-362(b)(3); 22 CFR § 41.2]An unexpired driver’s license issued by a Canadian government authority [O.C.G.A. § 50-36-2(b)(3); 8 CFR §274a.2]A Certificate of Citizenship issued by the United States Department of Citizenship and Immigration Services(USCIS) (Form N-560 or Form N-561) [O.C.G.A. § 50-36-2(b)(3); 6 CFR § 37.11]A Certificate of Naturalization issued by the United States Department of Citizenship and Immigration Services(USCIS) (Form N-550 or Form N-570) [O.C.G.A. § 50-36-2(b)(3); 6 CFR § 37.11]Certification of Report of Birth issued by the United States Department of State (Form DS-1350) [O.C.G.A. §50-36-2(b)(3); 6 CFR 37.11]Certification of Birth Abroad issued by the United States Department of State (Form FS-545) [O.C.G.A. § 5036-2(b)(3); 6 CFR 37.11]Consular Report of Birth Abroad issued by the United States Department of State (Form FS-240) [O.C.G.A. §50-36-2(b)(3); 6 CFR 37.11]An original or certified copy of a birth certificate issued by a State, county, municipal authority, or territory ofthe United States bearing an official seal [O.C.G.A. § 50-36-2(b)(3); 6 CFR 37.11]In addition to the documents listed herein, if, in administering a public benefit or program, an agency is required byfederal law to accept a document or other form of identification for proof of or documentation of identity, thatdocument or other form of identification will be deemed a secure and verifiable document solely for that particularprogram or administration of that particular public benefit. [O.C.G.A. § 50-36-2(c)]1Senate Bill 160 (Act No. 27), effective July 1, 2013, limited the use of passports issued by foreign nations tosatisfy the requirements for submission of secure and verifiable documents to only those passports submitted inconjunction with a United States Department of Homeland Security ("DHS") Form I-94, DHS Form I-94A, DHS FormI-94W, or other federal form specifying an individual's lawful immigration status or other proof of lawful presenceunder federal immigration law.0Page 9 of 12Rev. 3/11/22

Georgia Bureau of InvestigationGeorgia Crime Information CenterConsent FormGEORGIA BOARD OF MASSAGE THERAPYI hereby authorize toreceive anyGeorgia criminal history record information pertaining to me which may be in the files of any state or localcriminal justice agency in Georgia.Full Name (print)AddressSexRaceDate of BirthSocial Security NumberBy signing this form, I acknowledge that I have been informed of the Non-Criminal Justice Applicant’s PrivacyRights and the Privacy Act Statement (Title 28 United States Code § 534).SignatureDateSpecial employment provisions (check if applicable):Employment with mentally disabled (Purpose code 'M')Employment with elder care (Purpose code 'N')Employment with children (Purpose code 'W')You must select one of the four options below for the number of days for authorization:This authorization is valid for1. 90 days2. 180 days3. days from date of signature4. I, , give consent to the abovenamed to perform periodic criminal history background checks for the durationof my employment with this company.0Page 10 of 12Rev. 3/11/22

Attachment ANON-CRIMINAL JUSTICE APPLICANT'S PRIVACY RIGHTSAs an applicant that is the subject of a Georgia only or a Georgia and Federal Bureau of Investigation (FBI)national fingerprint/biometric-based criminal history record check for a non-criminal justice purpose (suchas an application for a

GEORGIA BOARD OF MASSAGE THERAPY. 237 Coliseum Drive, Macon, Georgia 31217-3858 (404) 424-9966 * sos.ga.gov/georgia-board-massage-therapy. GENERAL INSTRUCTIONS - REINSTATEMENT OF LICENSE Please read these instructions and the Georgia Law and Rules for Massage Therapy prior to completing this application.