1. 1. An application form that contains the licensee’s:

   1. a. Name;
   2. b. Massage therapy license number;
   3. c. Massage therapy license expiration date;
   4. d. Birthdate;
   5. e. Residence and practice addresses;
   6. f. Residence and practice telephone numbers;
   7. g. Mailing address;
   8. h. E-mail address;
   9. i. Alien status declaration if the licensee is not a citizen or national of the United States;

   10. j. Declaration of whether the licensee has been charged with or convicted of a felony or an offense involving moral turpitude or prostitution, solicitation, or a related offense or entered into a plea of no contest during the two-year period immediately preceding the renewal application date and, if so, the licensee shall provide the following information:

       1. i. The charged felony or offense;
       2. ii. The date of conviction;
       3. iii. The court having jurisdiction over the felony or offense;
       4. iv. The probation officer’s name, address, and telephone number, if applicable;
       5. v. A copy of the notice of expungement, if applicable; and
       6. vi. A copy of the restoration of civil rights, if applicable;
   11. k. Declaration that the licensee has completed the continuing education required by A.R.S. § 32-4225(E) during the two-year period immediately preceding the renewal application date or if audited, the documentation required in R4-15-303(B); and
   12. l. Signature and date of submission; and
2. 2. The fee required in R4-15-102(A).

An applicant for a renewal license shall submit:

Historical Note

New Section made by final rulemaking at 12 A.A.R. 2759, effective September 9, 2006 (Supp. 06-3). Amended by final rulemaking at 20 A.A.R. 2246, effective August 5, 2014 (Supp. 14-3).