Maryland State Board of Massage Therapy Examiners

4201 Patterson Avenue, Suite 301, Baltimore, Maryland 21215

Office Main Telephone: 410-764-4738;

Email : [email protected]; Website: https://health.maryland.gov/massage

Rev 09-2024

INSTRUCTIONS AND IMPORTANT INFORMATION

1. Name: If the name on the application form differs from the name on any of your supporting

documentation, you must submit a copy of a marriage license, divorce decree, or a court order

explaining the change of name. The Board must be notified of any change in your name within 60 days

or be subject to penalties. See COMAR 10.65.01.08.B; COMAR 10.65.01.14.

2. Social Security Number/Individual Taxpayer Identification Number (ITIN): Maryland law requires

the Board to collect either a Social Security Number or an ITIN from all individuals applying for any

professional license. The Board is permitted by State or Federal law to use these numbers for the

following purposes:

a. Administration of the Child Support Enforcement Program. See Md Code Ann., Family Law

§ 10-119.3

b. Identification by the State Department of Assessments and Taxation of new businesses in

Maryland. See Md. Code Ann., Health Occ. § 1-210.

c. Verification of identity with respect to final adverse actions related to your license. See 42

U.S.C. § 1320a-7e.

3. Date of Birth: Maryland law requires applicants for a license to practice massage therapy to be at least

18 years old. See Md. Code Ann., Health Occ. § 6-302(b)(2).

4. Personal Email/Work Email: Under the Maryland Public Information Act, those addresses identified

by the applicant as a business email address are PUBLIC and publicly disclosable on demand. See Md.

Code Ann., General Provisions § 4-333(b)(4). Please do not provide a private, personal email as your

“Work Email.”

5. Non-Public Address: The non-public (home) address is the location to which the Board will direct all

official correspondence. This address is confidential. Do not use your practice/business address. If you

change your address prior to being licensed or registered, immediately notify the Board.

6. Public Address: The public (practice/business) address is your public address of record and is available

to the public on demand. See Md. Code Ann., General Provisions § 4-333(b)(2). Do not provide the

Board with an address that you wish to remain confidential as your public address.

7. Home/Work Phone: These are the phone numbers at which the Board will attempt to reach you. Your

home phone number is held confidential.

8. Gender: Disclosure of gender is not a requirement for licensure, but the information provided will be

used for identification and statistical purposes.

Maryland State Board of Massage Therapy Examiners

4201 Patterson Avenue, Suite 301

Baltimore, Maryland 21215

Office Main Telephone: 410-764-4738

Instructions and Important Information

9. Licensure History: If you have ever held a license, certificate, or registration to practice massage

therapy in any state or jurisdiction or in ANY other health care profession in any other state or

jurisdiction, including Maryland, provide the requested information in the space provided.

10. Character and Fitness Questions: Answer the Character and Fitness Questions “YES” or “NO.” If you

answer “YES” to any item, please provide a detailed explanation on the last page of the application. If

necessary, you may attach any supporting documentation that you would like the Board to consider.

Failure to provide a detailed explanation of a “YES” response or failure to provide any documentation

on request by the Board will result in a delay in the processing of the application.

11. Fees: All fees submitted with an application are non-refundable.

12. Required documents to be submitted with this application.

• Completed and notarized application form

• $330 Application Fee payable to MD Board of Massage Therapy Examiners (non-refundable)

• Copy of valid driver’s license or state issued ID

• One (1) passport size photo

• Copy of Massage School Transcript

• Copy of Fingerprint receipt

• Copy of unexpired CPR Card (Healthcare Provider Level)

• Signed Privacy Act Statement

• Signed Online JP Policy Statement

• Signed Noncriminal Justice Applicant’s Privacy Rights

Active Military, Spouse of Active Military, Veterans or Spouse of Veteran:

• Copy of Military ID with application

• Spouse of Active Military or Veteran, provide Military ID of spouse and Copy of Marriage

Certificate

• Relocation Order (if applicable)

13. Documents to be sent directly to the MD Massage Therapy Board from primary source.

• Official Massage School Transcript

• Three (3) Moral Character References

• Official National Board Score

• Verification of Good Standing from out of state Board(s)

MARYLAND STATE BOARD OF MASSAGE THERAPY EXAMINERS

4201 Patterson Avenue, Suite 301, Baltimore, Maryland 21215

Office Main Telephone: 410 764-4738; Email Address: [email protected]

APPLICATION FOR LICENSE IN MASSAGE THERAPY

Revised 09-2024

BOARD USE ONLY

Check Date: ____________________ Check #: ____________________________________ Check Amount: _________________ Initials:___________

Please print or type all information. Do not leave any sections blank on the application.

DUCATION

ROFESSIONAL

RAINING

COMAR

10.65.01.06F)

Applicants must have graduated from an accredited massage school and a COMTA (or COMTA-equivalent) endorsed

curriculum and:

1. Provide documentation verifying a total of 750 hours which include program hours and continuing education hours; or

2. Has held a license/or registration continuously in good standing for a minimum of 10 years preceding application

submission; or

3. Attest to the accumulation of 1,000 hours of hands-on experience over the previous 2 years between work hours and

continuing education hours.

OUT-OF-STATE APPLICANTS ARE APPROVED ON A CASE-BY-CASE BASIS

Massage School:

_____________________________________________ State:___________________________

Completion Date:

______________ Contact Hours: ______________ Clinical Hours Completed:_______________

State & Location in which you completed your Hands-on Clinical Training: State: ___________________________

Name of Facility:

___________________________ Address of Facility: _________________________________

Name:_______________________________________________________________________________

(Last) (First) (Middle) (Maiden)

SSN or ITIN:

__________________________________ Date of Birth:____________________________

Personal Email (Required):__________________________ Work Email:____________________________

n-Public Address:_______________________________________________________________________

(Street) (City) (State) (Zip)

Public Address:__________________________________________________________________________

(Street) (City) (State) (Zip)

Home Phone: _____________________ Cell: _____________________ Work:______________________

Gender: Male Female Other (please state): ______________________ Pronoun:__________________

(Please specify)

Check Applicable Box: Active Military  Veteran  Spouse of Active Military or Veteran  N/A 

ICENSURE

ISTORY

Have you previously, or do you currently hold any professional license (including massage),

registration or certificate in this or any other state?  Yes  No If yes, please list the state(s)

1. State: __________________________________ Issuing Agency: _____________________________________

License #: ________________________ Date Issued: _______________ Expiration Date:__________________

2. State: __________________________________ Issuing Agency: _____________________________________

License #: ________________________ Date Issued: _______________ Expiration Date:__________________

Request all official verification(s) of “Good Standing” to be sent directly to the MD Board. List additional states on a

separate sheet.

Revised 09/2024

Applicant’s Name:

___________________________________

CRIMINAL HISTORY RECORDS CHECK

BACKGROUND, CHARACTER & FITNESS QUESTIONS

Please answer Yes or No to each question. If you answer Yes to any question, attach a separate page with a

complete explanation of each occurrence. Include date, time, location, disposition, etc., and a copy of the

disciplinary/court document (arrest, conviction, probation, rehabilitative programs, etc.) from the issuing

agency.

I affirm the answers provided above are true and accurate.

Initials

All applicants must complete a criminal history records check (CHRC) as part of the application process. The

guidelines and form for CHRC are attached to the application packet. Out of State applicants must contact

the MD Board at 410-764-4738 to request the fingerprint card. The fingerprint receipt must be included with

the application submitted to the Board.

CHRC RESULTS MUST BE RECEIVED BY THEBOARD BEFORE APPLICANTS MAY BE SCHEDULED FOR

THE MD JURISPRUDENCE EXAMINATION

YES



Has a state licensing or disciplinary board (including Maryland), a comparable body in the

armed services, or the Veterans Administration, denied your application for licensure,

registration, certification, reinstatement, reactivation or renewal?

2. 



Has a state licensing or disciplinary board (including Maryland), a comparable body in the

armed services or the Veterans Administration, taken action against your license, registration,

certificate? Such actions include, but are not limited to, limitations of practice, required

education, admonishment or reprimand, suspension, probation or revocation.

3. 



Has any licensing or disciplinary board in any jurisdiction (including Maryland), a comparable

body in the armed services or the Veterans Administration, filed any complaints or charges

against you or investigated you for any reason?

4. 



Have you ever pled guilty, nolo contendre, no contest, or been convicted or received probation

before judgment for any criminal act (felony or misdemeanor), including DWI or DUI, in any

state of jurisdiction?

5. 



Have you surrendered your license, registration or certificate or allowed it to lapse while you

were under investigation by any licensing or disciplinary board of any jurisdiction, or any entity

of the armed services or the Veterans Administration?

6. 



Do you currently have any condition or impairment (including, but not limited to, substance

abuse, alcohol abuse, or a physical, mental, emotional, or nervous disorder/condition) that in

any way affects your ability to practice massage therapy in a safe, competent, ethical, and

professional manner?

7. 



Have any malpractice claims or other claims for money damage been filed against you? Include

past and pending claims, dismissed or settled claims, or claims which resulted in a damages

award against you.

Ethnicity:  Hispanic/Latino  Not Hispanic or Latino

To further its commitment to equal opportunity, the Board of Massage Therapy Examiners requests applicants voluntarily

provide the following information.

Race: (please check all that apply):

Asian White Black/African American Native Hawaiian/Pacific Islander American Indian/Alaska Native

Other ________________________________ (Please specify)

Revised 09/2024

Applicant’s Name:

___________________________________

PROFESSIONAL REFERENCES

Pursuant to Md. Code Ann., Health Occ. § 6-302, applicants are required to have good moral character

in order to be licensed. To that end, please provide the names and contact information of three (3)

Professional References that can attest to your massage therapy skills and moral character. These

persons should work in the massage therapy field such as instructors, professors, independent

practitioners or individuals in related professions such as chiropractic, physical therapy, or medicine.

These individuals shall each complete a Certificate of Moral Character and send it directly to the

Board.

1. Name: ______________________________ Occupation:_______________________

Address: ____________________________ License No.: ______________________

____________________________

Phone No.: _______________________

Email: _________________________________________________________________

Name: ______________________________ Occupation:_______________________

Address: ____________________________ License No.: ______________________

____________________________

Phone No.: _______________________

Email: _________________________________________________________________

Name: ______________________________ Occupation:_______________________

Address: ____________________________ License No.: ______________________

____________________________

Phone No.: _______________________

Email: _________________________________________________________________

CHECKLIST OF REQUIRED DOCUMENTS TO BE SUBMITTED WITH THIS APPLICATION

Please check the documents you are including with this application:

 $330 Application Fee payable to MD Board of Massage Therapy Examiners

 Copy of valid driver’s license or state issued ID One (1) passport size photo

 Copy of Massage School Transcript Copy of Fingerprint receipt

 Copy of National Exam Score Report Signed Privacy Act Statement

 Copy of unexpired CPR Card (Healthcare Provider Level) Online JP Policy Statement

 Signed Noncriminal Justice Applicant’s Privacy Rights

VETERAN OR SPOUSE OF VETERAN

 Copy of Military ID with application.

 Spouse of Veteran, provide Military ID of spouse and Copy of Marriage Certificate.

 Relocation Order (if applicable)

DOCUMENTS I HAVE REQUESTED TO BE SENT DIRECTLY TO THE MD BOARD

Please check all that apply:

 Official Massage School Transcript  Three (3) Moral Character References

 Official National Board Score  Verification of Good Standing from out of state Board(s)

OFFICIAL TRANSCRIPTS, NATIONAL BOARD SCORE AND CHRC RESULTS MUST BE RECEIVED BY THE BOARD

BEFORE APPLICANTS MAY BE SCHEDULED FOR THE MD JURISPRUDENCE EXAMINATION.

Revised 09/2024

Applicant’s Name:

___________________________________

JURISPRUDENCE EXAMINATION POLICY

You may not receive any assistance from other individuals in

taking this exam, and you may not allow other individuals to see

the computer screen that presents the exam questions.

Pursuant to Md. Code Ann. Health Occ 6-308(a), the Board

may not only deny the application of an Applicant but also may

take disciplinary action against a licensee that obtained a

license through cheating. Those actions may include revocation

of said licensure.

It should be noted that an applicant, licensee, or entity may not

possess the Board’s Jurisprudence Examination, nor may those

individuals record, save questions, or share any part of the

examination with others.

I have read, understand and agree to abide by the above-stated

requirements.

Signature: _______________________________ Date:______________

Revised 09/2024

Applicant’s Name:

___________________________________

JURISPRUDENCE EXAMINATION (JP) FAILURE POLICY

STUDY MATERIALS

The following policy pertains to applicants for massage licensure. There are no waivers or exceptions

to the following:

•

All applicants shall take and successfully pass the Board’s Online Jurisprudence Examination

(JP) to qualify for licensure.

•

STUDY MATERIALS. The Board recommends that applicants study the laws and

regulations prior to taking the examination. Use these links to access the study materials.

Massage Laws Massage Regulations (COMAR)

•

If an applicant passes the JP, the applicant’s file will advance to the next stage of processing.

•

All applicants must take the JP within the timeframe specified in the JP Admittance

and logon id email notification received from the Board. ________Initials

•

Candidates are allowed two (2) attempts to pass the JP.

•

An applicant failing the JP twice may retest after waiting at least thirty (30) days after taking the

last JP, and submitting a Retake Registration form plus the $250 non-refundable fee.

•

An applicant failing the JP a third time may retest only after waiting at least thirty (30) days

from the date of the third JP failure, meeting with the Board at its request, and recommended

approval by the Board. ________ Initials

•

An applicant’s file shall be closed/terminated one (1) year from the original application

date regardless of the status of the applicant in the JP process. At such occurrence, the

applicant may reapply and submit all required fees, documentation, and an

application form as a new applicant. Any/all previous JP failures will be applied to the new

application. For example, an applicant failing the JP three (3) times under the first application

and then reapplying after a lapse of one year, will still have three (3) failures credited to the

application and will require approval of the Board to retest. ________ Initials

•

All fees are non-refundable. ________ Initials

ACKNOWLEDGEMENT

I have read, understand fully and consent to the provisions of the above stated policy.

Signature: ________________________________________ Date: __________________

Revised 09/2024

Applicant’s Name:

___________________________________

Please provide one (1) passport type,

color, head and shoulder photo on a

solid background.

Photo must be 2”x2” or 2”x3”. Full

body photo is not acceptable.

Affix photo to this box.

ATTESTATION

I agree to abide by the laws and regulations governing the practice of massage therapy found in

Maryland Code Annotated, Health Occupations Article §§6-101 et seq. and in the Code of

Maryland Regulations 10.65.01 et seq., and to take all examinations necessary for the processing

of my application. Upon issuance of a license, I agree to be bound by the Code of Ethics.

_____________ Initial

I have read the Massage Therapy statute and regulations. I acknowledge and agree that the

burden is solely on me to produce adequate and acceptable proof of educational, professional and

character qualifications sufficient to meet the requirements for licensure.

I agree to hold the Maryland State Board of Massage Therapy Examiners, its members, officers,

staff, agents and examiners free from any damage or claim for damage or complaints by reason of

any action they or any one of them take in connection with this application, the examination, the

grades, with respect to any examination, and/or failure of the Board to issue me a license. I hereby

grant permission to the Board to seek any and all information or references it deems fit in securing

my credentials pertinent to this application. I further agree that if issued a license to practice massage

therapy, upon suspension, revocation, or cancellation of such license, within five business days, of

such action, I shall return the official license back to the Board.

The information provided in this application is truthful and correct to the best of my knowledge and

belief. I understand that providing false information of any kind or omitting information known to

me may result in the voiding of this application. I agree that all documents submitted with this

application are the property of the Board and all fees are non-refundable.

_________________________ _____________________________ ______________

Print Name Applicant’s Signature Date

NOTARY CERTIFICATION:

State:_____________________________ City/County:_____________________________________

The undersigned notary public attests that the above-signed individual/applicant has presented photo

identification and has signed the above under oath/affirmation.

Signed and sworn before me this _________ day of___________________________, ____________.

________________________________________ ________________________

Name and signature Date My Commission Expires

NOTARY SEAL

Revised 09/2024

Applicant’s Name:

___________________________________

MARYLAND STATE BOARD OF MASSAGE THERAPY EXAMINERS

4201 Patterson Avenue, Suite 301, Baltimore, MD 21215

Office (410) 764-4738 Email: [email protected]

CERTIFICATE OF MORAL CHARACTER

To be completed by a licensed massage therapist/practitioner in good standing or an instructor and

send directly to the Board. Do not include with application package.

I, _______________________________________ hereby certify that I am personally and/or

professionally acquainted with ______________________________________ (Name of

Applicant) and I am able to attest to his/her moral character and ability to professionally serve as a

massage therapist and protect the healthcare of the citizens of Maryland.

Please describe the manner in which you are familiar with the Applicant, including the length of time

you have known him/her.

______________________________________________________________________

(Check One) ___________ Applicant is of good moral character, and I recommend him/her for

licensure by the Maryland State Board of Massage Therapy Examiners.

__________ I do not recommend Applicant for licensure by the Maryland State Board

of Massage Therapy Examiners. Please attached a detailed explanation.

I attest that the information provided is true and correct to the best of my knowledge and beliefs.

____________________________ ____________________________ _________

Print Name and Credentials Signature Date

________________ ______________________ _______________ ______________

License Number Issuing State Issue Date Expiration Date

______________________________________________________________________

Street Address City State Zip

__________________________________ _____________________________

Contact Phone Number(s) Email

PLEASE RETURN THE COMPLETED FORM DIRECTLY TO THE BOARD by mail or email at

mdh.bcmte@maryland.gov

Are you aware of any facts relating to misconduct, administrative, criminal, or civil action against the

Applicant that may affect the Applicant’s abilities as a massage professional?

No Yes If yes, please attach a detailed explanation to this page.

Revised 09/2024

Applicant’s Name:

___________________________________

CHARACTER & FITNESS EXPLANATION

CRIMINAL HISTORY RECORDS CHECK BACKGROUND QUESTIONS

Applicant:

____________________________________

Privacy Act Statement

This privacy act statement is located on the back of the FD-258 fingerprint card.

Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated

information is generally authorized under 28 U.S.C. 534. Depending on the nature of your

application, supplemental authorities include Federal statutes, State statutes pursuant to

Pub. L. 92-544, Presidential Executive Orders, and federal regulations. Providing your

fingerprints and associated information is voluntary; however, failure to do so may affect

completion or approval of your application.

Principal Purpose: Certain determinations, such as employment, licensing, and security

clearances, may be predicated on fingerprint-based background checks. Your fingerprints and

associated information/biometrics may be provided to the employing, investigating, or otherwise

responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other

fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems

(including civil, criminal, and latent fingerprint repositories) or other available records of the

employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints

and associated information/biometrics in NGI after the completion of this application and, while

retained, your fingerprints may continue to be compared against other fingerprints submitted to

or retained by NGI.

Routine Uses: During the processing of this application and for as long thereafter as your

fingerprints and associated information/biometrics are retained in NGI, your information may be

disclosed pursuant to your consent, and may be disclosed without your consent as permitted by

the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the

Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine

Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or

authorized non-governmental agencies responsible for employment, contracting, licensing,

security clearances, and other suitability determinations; local, state, tribal, or federal law

enforcement agencies; criminal justice agencies; and agencies responsible for national security or

public safety.

As of 03/30/2018

Applicant’s Signature: ________________________________ Date: _______________

See Page 2 for Spanish translation.

Solicitante________________________________

Declaración de la Ley de Privacidad

Esta declaración de la ley de privacidad se encuentra al dorso del

FD-258 tarjeta de huellas digitales.

Autoridad: La adquisición, preservación, e intercambio de huellas digitales e información

relevante por el FBI es autorizada en general bajo la 28 U.S.C. 534. Dependiendo de la

naturaleza de su solicitud, la autoridad incluye estatutos federales, estatutos estatales de acuerdo

con la Pub. L. 92-544, Órdenes Ejecutivas Presidenciales, y reglamentos federales. El proveer

sus huellas digitales e información relevante es voluntario; sin embargo, la falta de hacerlo

podría afectar la terminación o aprobación de su solicitud.

Propósito Principal: Ciertas determinaciones, tal como empleo, licencias, y autorizaciones de

seguridad, podrían depender de las investigaciones de antecedentes basados en huellas

digitales. Se les podría proveer sus huellas digitales e información relevante/ biométrica a la

agencia empleadora, investigadora, o responsable de alguna manera, y/o al FBI con el

propósito de comparar sus huellas digitales con otras huellas digitales encontradas en el

sistema Next Generation Identification (NGI) del FBI, o su sistema sucesor (incluyendo los

depósitos de huellas digitales latentes, criminales, y civiles) u otros registros disponibles de la

agencia empleadora, investigadora, o responsable de alguna manera. El FBI podría retener sus

huellas digitales e información relevante/biométrica en el NGI después de terminar esta

solicitud y, mientras las mantengan, sus huellas digitales podrían continuar siendo comparadas

con otras huellas digitales presentadas a o mantenidas por el NGI.

Usos Rutinarios: Durante el procesamiento de esta solicitud y mientras que sus huellas digitales

e información relevante/biométrica permanezcan en el NGI, se podría divulgar su información

de acuerdo a su consentimiento, y se podría divulgar sin su consentimiento de acuerdo a lo

permitido por la Ley de Privacidad de 1974 y todos los Usos Rutinarios aplicables según puedan

ser publicados en el Registro Federal, incluyendo los Usos Rutinarios para el sistema NGI y los

Usos Rutinarios Generales del FBI. Los usos rutinarios incluyen, pero no se limitan a

divulgación a: agencias empleadoras gubernamentales y no gubernamentales autorizadas

responsables por emplear, contratar, licenciar, autorizaciones de seguridad, y otras

determinaciones de aptitud; agencias de la ley locales, estatales, tribales, o federales; agencies

de justicia penal; y agencias responsables por la seguridad nacional o seguridad pública.

A partir de 30/03/2018

Firma del solicitante ________________________________ Fecha _______________

Applicant: _____________________________

Update Date 6/11/2019

NONCRIMINAL JUSTICE APPLICANT’S PRIVACY RIGHTS

As an applicant who is the subject of a national fingerprint-based criminal history record check for

a noncriminal justice purpose (such as an application for employment or a license, an immigration

or naturalization matter, security clearance, or adoption), you have certain rights which are

discussed below. All notices must be provided to you in writing.

1 These obligations are pursuant to

the Privacy Act of 1974, Title 5, United States Code (U.S.C.) Section 552a, and Title 28 Code of

Federal Regulations (CFR), 50.12, among other authorities.

• You must be provided an adequate written FBI Privacy Act Statement (dated 2013 or later

)

hen you submit your fingerprints and associated personal information. This Privacy Act

Statement must explain the authority for collecting your fingerprints and associated

information and whether your fingerprints and associated information will be searched,

shared, or retained.

• You must be advised in writing of the procedures for obtaining a change, correction, or

update of your FBI criminal history record as set forth at 28 CFR 16.34.

• You must be provided the opportunity to complete or challenge the accuracy of the

information in your FBI criminal history record (if you have such a record).

• If you have a criminal history record, you should be afforded a reasonable amount of time

to correct or complete the record (or decline to do so) before the officials deny you the

employment, license, or other benefit based on information in the FBI criminal history

record.

• If agency policy permits, the officials may provide you with a copy of your FBI criminal

history record for review and possible challenge. If agency policy does not permit it t

rovide you a copy of the record, you may obtain a copy of the record by submittin

ingerprints and a fee to the FBI. Information regarding this process may be obtained at

https://www.fbi.gov/services/cjis/identity-history-summary-checks a

https://www.edo.cjis.gov.

• If you decide to challenge the accuracy or completeness of your FBI criminal history record,

you should send your challenge to the agency that contributed the questioned information

to the FBI. Alternatively, you may send your challenge directly to the FBI by submitting a

request via https://www.edo.cjis.gov. The FBI will then forward your challenge to th

agency that contributed the questioned information and request the agency to verify or

correct the challenged entry. Upon receipt of an official communication from that agency,

the FBI will make any necessary changes/corrections to your record in accordance with the

information supplied by that agency. (See 28 CFR 16.30 through 16.34.)

• You have the right to expect that officials receiving the results of the criminal history record

check will use it only for authorized purposes and will not retain or disseminate it in

violation of federal statute, regulation or executive order, or rule, procedure or standard

established by the National Crime Prevention and Privacy Compact Council.

1 Written notification includes electronic notification, but excludes oral notification.

https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement

See 5 U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616), Article IV(c);

28 CFR 20.21(c), 20.33(d) and 906.2(d).

Applicant’s Signature:

_____________________________________

Date:

_________________

Solicitante: ___________________________________ 2

Actualizado 6/11/2019

DERECHOS DE PRIVACIDAD DE SOLICITANTES - JUSTICIA, NO CRIMINAL

Como solicitante sujeto a una indagación nacional de antecedentes criminales basado en huellas

dactilares, para un propósito no criminal (tal como una solicitud para empleo o una licencia, un

propósito de inmigración o naturalización, autorización de seguridad, o adopción), usted tiene

ciertos derechos que se entablan a continuación. Toda notificación se le debe proveer por escrito.

Estas obligaciones son de acuerdo al Privacy Act of 1974, Title 5, United States Code (U.S.C.)

Section 552a, y Title 28 Code of Federal Regulations (CFR), 50.12, entre otras autorizaciones.

• Se le debe proveer una Declaración de la Ley de Privacidad del FBI (con fecha de 2013 o

más reciente) por escrito cuando presente sus huellas digitales e información personal

relacionada. La Declaración de la Ley de Privacidad debe explicar la autorización para

tomar sus huellas digitales e información relacionada y si se investigarán, compartirán, o

retendrán sus huellas digitales e información relacionada.

• Se le debe notificar por escrito el proceso para obtener un cambio, corrección, o

actualización de su historial criminal del FBI según delineado en el 28 CFR 16.34.

• Se le tiene que proveer una oportunidad de completar o disputar la exactitud de la

información contenida en su historial criminal del FBI (si tiene dicho historial).

• Si tiene un historial criminal, se le debe dar un tiempo razonable para corregir o completar

el historial (o para rechazar hacerlo) antes de que los funcionarios le nieguen el empleo,

licencia, u otro beneficio basado en la información contenida en su historial criminal del

FBI.

• Si lo permite la política de la agencia, el funcionario le podría otorgar una copia de su

historial criminal del FBI para repasarlo y posiblemente cuestionarlo. Si la política de la

agencia no permite que se le provea una copia del historial, usted puede obtener una copia

del historial presentando sus huellas digitales y una tarifa al FBI. Puede obtener

información referente a este proceso en https://www.fbi.gov/services/cjis/identity-history-

summary-checks y https://www.edo.cjis.gov.

• Si decide cuestionar la veracidad o totalidad de su historial criminal del FBI, deberá

presentar sus preguntas a la agencia que contribuyó la información cuestionada al FBI.

Alternativamente, puede enviar sus preguntas directamente al FBI presentando un petición

por medio de .https://www.edo.cjis.gov. El FBI luego enviará su petición a la agencia que

contribuyó la información cuestionada, y solicitará que la agencia verifique o corrija la

información cuestionada. Al recibir un comunicado oficial de esa agencia, el FBI hará

cualquier cambio/corrección necesaria a su historial de acuerdo con la información proveída

por la agencia. (Vea 28 CFR 16.30 al 16.34.)

• Usted tiene el derecho de esperar que los funcionarios que reciban los resultados de la

investigación de su historial criminal lo usarán para los propósitos autorizados y que no los

retendrán o diseminarán en violación a los estatutos, normas u órdenes ejecutivos federales,

o reglas, procedimientos o normas establecidas por el National Crime Prevention and

Privacy Compact Council.

1 La notificación por escrito incluye la notificación electrónica, pero excluye la notificación verbal.

2 https://www.fbi.gov/services/cjis/compact-council/privacy-act-statement

3 Vea 5 U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (anteriormente citada como 42 U.S.C. § 14616),

Article IV(c); 28 CFR 20.21(c), 20.33(d) y 906.2(d)

Firma del solicitante: ___________________________________________ Fecha: ______________

ARYLAND STATE BOARD OF MASSAGE THERAPY EXAMINERS

4201 Patterson Avenue, Suite 301, Baltimore, MD 21215

Office (410) 764-4738

www.health.maryland.gov/massage

CRIMINAL HISTORY RECORDS CHECK INSTRUCTIONS & FORM

A full Criminal History Records Check (CHRC) is a requirement for a license from the Maryland State

Board of Massage Therapy Examiners. This background check includes a search of both a State and FBI

database. The Department of Public Safety and Correctional Services’ Criminal Justice Information

System (CJIS) oversees Criminal History Record Checks. Fingerprints are used to complete the Criminal

History Records Check.

Information you will need to complete the fingerprint form for the background check is provided below:

• CJIS AUTHORIZATION #: 1600004151

• FBI ORI #: MD 920519Z

• REASON FINGERPRINTED: License/Registration

• TYPE OF CHECK: Governmental Licensing/Certification

The cost is $55.00 ($31.25 for background check and $23.75 for fingerprinting service). The background

check fee is paid to CJIS. The fingerprinting service fee must be paid directly to the provider. The cost of

fingerprinting services from private providers may vary. Check with the provider to determine what

forms of payment are accepted. For additional information contact CJIS at 410-764-4501 or visit

www.dpscs.maryland.gov/publicservs/fingerprint.shtml.

In order to not delay the issuance of a license, applicants must adhere to the following directions:

MARYLAND RESIDENT

1. Print and fill out a copy of the attached “Livescan Pre-registration Form”. Go to

www.dpscs.maryland.gov/publicservs/fingerprint.shtml for a list of commercial fingerprint

providers near you. Take the “Livescan Pre-registration Form” to the commercial fingerprint

provider with you. Do not sign the form until you are in the presence of the individual taking

your fingerprints.

2. When you have your fingerprints taken you will be given a receipt for payment. Include a copy of

the receipt when filing your initial application.

3. Your application package is complete only after the Board receives the results of the background

check. The results can take up to four weeks after initial fingerprinting. For additional

information contact CJIS at 410 764-4501 or visit

www.dpscs.maryland.gov/publicservs/fingerprint.shtml

OUT OF STATE RESIDENT

1. Before submitting a completed application, contact the Board at 410 764-4738 to request an “Out

of State Application for Criminal History Record Check” card.

Note: If you are in, or work close to Maryland you may elect to print out and

complete a copy of the attached “Livescan Pre registration Form”. Go to

www.dpscs.maryland.gov/publicservs/fingerprint.shtml for a list of commercial

Maryland fingerprint providers near you. Take the “Livescan Pre-registration Form”

to the commercial fingerprint provider with you to be fingerprinted. Do not sign the

form until you are in the presence of the individual taking your fingerprints.

2. Have your fingerprints taken at a law enforcement agency near you.

3. Once you have your prints taken, mail the fingerprint cards to the address below with a check for

$31.25 made out to the "CJIS Central Repository". No cash or money orders.

Mail To:

CJIS Central Repository

P.O. Box 32708

Pikesville, Maryland 21282-2708

4. Include a copy of the receipt for the fingerprinting with your application package and mail to:

Maryland State Board of Massage Examiners

Attention: Licensing Coordinator

4201 Patterson Avenue, Suite 301

Baltimore, Maryland 21215

5. Once the results of the background check are received by the Board, which can take up to four

weeks, the application package will be complete.

FINGERPRINT CARD DIRECTIONS

The State of Maryland will not accept fingerprints done on the card from another state. The preprinted

information on the card sent to you will direct CJIS were to send the results.

Do not sign the form until you are in the presence of the individual taking your fingerprints.

STATE OF MARYLAND

DEPARTMENT OF PUBLIC SAFETY AND CORRECTIONAL SERVICES

CRIMINAL JUSTICE INFORMATION SYSTEMS – CENTRAL REPOSITORY

LIVESCAN PRE-REGISTRATION APPLICATION

APPLICANT INFORMATION

(PLEASE TYPE OR PRINT CLEARLY)

Name:

Date of birth:

SSN:

Gender: Male Female

(Please check)

Height: ft. inches

Weight: lbs.

Eye Color:

Hair Color:

Race: Black White Asian/Pacific Islander Native American Other

(Please check)

Place of Birth:

Citizenship:

Current address:

City:

State:

ZIP Code: -

Daytime Phone:

Evening Phone:

Driver’s License #:

AGENCY INFORMATION

Agency Authorization #: 1600004151

ORI # (if required): MD 920519Z

Reason fingerprinted? LICENSURE / REGISTRATION

Position Applied for: MDH - MD STATE BOARD OF MASSAGE THERAPY EXAMINERS

Request Type:

(Choose one ONLY)

Adult Dependent Care

Attorney/Client

Child care

Criminal Justice

Gold Seal/ Adoption

Gold Seal/Letter/VISA

Government Employment

Government Licensing or Certification

Immigration/VISA

Individual Challenge

Individual Review

MSP Licensing

Private Party Petition

Public Housing

Mail Response to:

(Mailing option only available for Visa Gold Seal and/or Individual Review)

ame:

________________________________________________________________________________________

ddress:

______________________________________________________________________________________

City, State, Zip code:

______________________________________________________________________________