TEXAS DEPARTMENT OF STATE HEALTH SERVICES
MASSAGE THERAPY PROGRAM
P.O. Box 149347, Mail Code 2003 * Austin, Texas 78714-9347
Budget ZZ121
Fund 105
CE RENEWAL
Continuing Education Provider
Agreement
Read the attached massage therapy rules (25 Texas Administrative Code, Chapter 140) relating to continuing
education before you complete this form. By completing and signing this document you agree to present
continuing education programs in accordance with the rules. Renewal Fee Enclosed: $ 200.00
Name:
Address:
City:
State:
Zip:
Social Security #
Telephone Number:
CE Provider Number________________ MT Number_______________ MI Number__________________
Renewal Amount Due: $ 200.00
Acceptable continuing education offered shall directly relate to directly related to the theory or clinical
application of theory pertaining to the practice of massage therapy and the manipulation of soft tissue, massage
therapy laws and rules, business practices, professional ethics, anatomy, physiology, hydrotherapy, kinesiology,
pathology, or health and hygiene; or first aid and/or CPR, not to exceed six hours total each renewal period; or
advanced massage therapy or bodywork techniques acceptable to the department; and designed to increase and
enhance professional knowledge, skills, or competence in the practice of massage therapy as cited in 25 TAC
§140.321(a). Continuing education approved or recognized by the department must be developed and presented
by a qualified person as cited in §140.321(b). Massage therapy techniques and courses involving the
manipulation of soft tissue must be taught or presented by a massage therapy instructor.
I hereby certify that all programs offered by this provider will comply with the Texas Department of State
Health Service’s administrative rules pertaining to the provision of continuing education as set out in 25 Texas
Administrative Code (TAC), §140.320 through §140.324. I further certify that I will maintain records
pertaining to all continuing education activities presented under this pre-approved number as cites in
§140.323(d) and provide certificates of attendance in accordance with §140.323(e) I understand that failure to
provide programs in accordance with the rules may result in the loss of my provider status.
Printed Name of Provider:
Signature of Provider:
DSHS Massage Therapy Licensing Program Revised 4/09