TEXAS DEPARTMENT OF STATE HEALTH SERVICES
MASSAGE THERAPY LICENSING PROGRAM
Mail Code 2003, P.O. Box 149347, Austin, Texas 78714-9347
Budget ZZ121
Fund 105
CE APPLICATION
Continuing Education Provider
Application/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.
Proof of passing the Jurisprudence Exam (which covers Texas law and rules related to massage therapy) is required for all applications postmarked on or after 6/1/09. The Jurisprudence Exam fee of $40.00 must be paid online at: http://www.dshs.state.tx.us/massage/mt_jurisprudence.shtm
Application Fee: $200.00
Name:
Address:
City:
Social Security #
State: Zip:
Telephone Number: Date of Birth:
MT Number :_________Expiration Date_________ MI Number:_________ Expiration Date__________
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:
Publication #; F64-13023, Electronic #: EF64-13023
DSHS Massage Therapy Licensing Program Revised 5/09