B. An applicant for a regular license shall
meet the requirements in A.R.S. §
32-4222(A)
and (B) before submitting an application
packet that contains:
1. An application form
that includes:
a. The applicant's name, date
of birth, place of birth, social security number, email address, residence and
business addresses, residence and business telephone numbers, and mailing
address, if applicable;
b. The
applicant's race, gender, height, weight, and eye color;
c. Each name or alias previously or currently
being used by the applicant;
d. The
applicant's name as it will appear on the license;
e. To satisfy the
requirements in A.R.S. §
32-4222(A)(5):
i. If the applicant graduated from a high
school, the date of graduation and name of the high school;
ii. If the applicant received a high school
equivalency diploma, the date the high school equivalency diploma was awarded;
or
iii. If the applicant passed an
ability to benefit examination recognized by the United States Department of
Education, written documentation of passage;
f. One passport quality photograph of the applicant's
head and shoulders no larger than 2 1/2 by 3 inches taken no more than 60 days
before the date of the application;
g. The name and address
of each Board-recognized school attended by the applicant, dates of attendance,
and date of completion of the course of study;
h. The number of hours of classroom and
clinical instruction completed by the applicant at a Board-recognized
school;
i. Whether the applicant has passed the examination
administered by the NCBTMB or FSTMB and if so, the name of the entity and date
the examination was taken;
j.
Whether the applicant has been 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 and, if so:
i.
Charged felony or offense;
ii. Date
of conviction;
iii. Court having
jurisdiction over the felony or offense;
iv. Probation officer's name, address, and
telephone number, if applicable;
v.
A copy of the notice of expungement, if applicable; and
vi. A copy of the notice of restoration of
civil rights, if applicable;
k. Whether the applicant currently holds or
has held a massage therapy license issued by another state and if so, the name
of each state;
l. Whether the
applicant has ever voluntarily surrendered a license under A.R.S. §
32-4254
or had a license to practice massage therapy or another related license revoked
by a political subdivision of this state or a regulatory board in another
jurisdiction in the United States for an act that occurred in that jurisdiction
that would be subject to discipline pursuant to this Chapter;
m. Whether the applicant is currently under
investigation, suspension, or restriction by a political subdivision of this
state or a regulatory board in another jurisdiction in the United States for an
act that occurred in that jurisdiction that would be subject to discipline
pursuant to this Chapter;
n.
Whether the applicant has committed any of the actions or been subject to any
of the actions listed in the definition of good moral character in
R4-15-101;
o. Whether English is
the applicant's native language and, if not:
i. What the applicant's native language is,
and
ii. Whether the applicant has
met the requirements in subsection (C); and
p. A notarized statement, signed by the
applicant, stating: the information on the application form is true and
correct;
2. Documentation
of citizenship or alien status that meets the requirements in A.R.S. §
41-1080;
3. A completed and legible fingerprint card;
and
4. The fee required in
R4-15-102.