California Massage Therapy Council

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California Massage Therapy Council

Certificate Holder

1. CAMTC Certificate Number :
2. Name :
First Name :		Last Name :
Middle Name :

3. Home Address :
Street :

City :	State :	Zip :

4. Is your Mailing Address the same as the above Home Address where you live?

Yes

If you answered "No" to the question above, then you must provide your current Mailing Address below. You are also required by law to provide your primary email address, if you have one. Please remember that your Application may be denied, delayed, or you may be required to pay additional processing fees if you provide CAMTC with an incorrect Mailing Address.

Mailing Address :

Street :

City :

State :

Zip :

Primary Phone :		Mobile
Secondary Phone :		Mobile


Website :
Primary Email :
Secondary Email :

Work Information

5.	Please provide the following WORK INFORMATION for ALL locations where you CURRENTLY provide Massage Therapy Services and for all massage businesses you CURRENTLY own or operate.

Business Name

Start Date

End Date

Business Phone

City

State

Zip

Action

6.	Please provide all of your Previous Massage Work Locations within the past ten (10) years. Please include ALL locations where you have provided Massage Therapy services and every massage business you have owned or operated in the past ten (10) years.

Business Name

Start Date

End Date

Business Phone

City

State

Zip

Action

APPLICANT HISTORY SECTION

{{h.ContentItemNumber - 1}} .

Yes

Note :

You will not be able to enter information until you read the instructions.

Provide a detailed description of the incident that lead to the action being taken against you including the date of the incident :

From Date :

To Date :

Provide the location where the incident occurred and whether it occurred at a location where massage is provided :

Location/Name of Business :

Address :

City :

State :

Zip :

Massage provided at that location :

Yes

Was the incident related to massage services? :

Yes

Identify the place where the formal complaint is pending (city, county, state, or country) :

Describe the nature of the complaint and provide a detailed description of the incident that resulted in the complaint including the date of the incident :

Nature of complaint :

Describe in your own words what happened :

With whom was the complaint filed?

Provide any identifying information you have in relation to the complaint, such as case number, etc. :

What is the current status of the complaint?

Describe what was acted against (a permit, license, certificate, business license, operator’s permit, etc.) :

Describe the specific action(s) taken against you (for example - did you have a permit revoked, paid a fine, had a state license disciplined, had your application denied, etc.) :

The date of the citation or the date the action against you occurred :

From Date :

To Date :

Identify the agency that took the action against you (city, county, state, etc.) :

The stated reason for the action being taken against you (for example – a massage professional failed to properly cover a client, the business used an un-permitted or un-certified person to provide massage services, etc.) :

Identify who made the complaint (for example – the client, the spouse of a client, the parent of a client, a neighbor, etc.) :

Identify who the complaint was made against (for example – you, a massage professional working at your establishment, etc.) :

List the specific charge(s) filed against you :

Identify the arresting agency :

Where is the court located or jurisdiction?

Describe the sanctions, penalties, or probationary terms imposed and completion dates. Use the ‘Add’ button to list each sanction, penalty or probationary term imposed and the completion date separately :

Terms imposed :

Completion date :

Terms Imposed

Completion Date

Action

Describe in your own words what happened that led to your registration :

Date of conviction :

From Date :

To Date :

List the specific charge(s) convicted of :

Is this a lifetime registration?

Yes

List all locations, dates and periods of registration below. Use the 'Add' button for each registration :

Location of registration :

Registration date :

Registration period :

Location of registration

Registration date

Registration period

Action

Any other information that you would like to share with us :

Please also provide copies of any documentation you have in relation to the action taken against you (for example – copies of administrative citations, judgments, receipts for fines paid, final decision letters from the agency that took action against you, etc.).

Document Name

Document Type

Link

document details

Failure to fully disclose requested information is a violation of the law and is considered an attempt to procure a certificate by fraud, misrepresentation, or mistake and is grounds for denial of certification or revocation of certification.

APPLICANT AFFIDAVIT RECORD RELEASE


	Yes

Signature :

Date :

Payment

Recertification Fee (includes ONE original CAMTC certificate) : ${{RecertificationFees | number: 2}}
(By law you must display an original CAMTC certiﬁcate at each business location where you provide massage for compensation.)

I understand that my Application Fee is non-refundable regardless of the ultimate disposition of my application.

Payment Method :
Recertification Fees :		$ {{RecertificationFees}}
Total number of additional original certificates requested :		x ${{AdditinolCertiCost \| number: 2}} each
Fee for all Additional Original Certificates requested :		$ {{FeeForAdditional * 1}}
Late Fee :	$	$ {{ReLateFee}}
Total fee (incl. recert. App. and add. original certs) :		$ {{TotalFee}}
Check # :		{{CheckNo}}
Money Order # :		{{OrderNo}}
Reference Number :		{{ReferenceNumberPayment}}
InvoiceDate :		{{InvoiceDatePayment \| date : 'MM/dd/yyyy'}}

Check # :
Comment :	{{CheckComment}}
	I am mailing my payment(payment must be received within 10 days of submitting the application otherwise your application will be denied)

Money Order # :
Comment :	{{MoneyOrderComment}}
	I am mailing my payment(payment must be received within 10 days of submitting the application otherwise your application will be denied)

Paid

Payment

SECURE PAYMENT PORTAL

Application Name :	Recertification Application	Application Id :	{{ApplicationId}}
Invoice Number :	{{InvoiceId}}

Order Information

Application Fee :		US ${{RecertificationFees \| number: 2}}
Additional Certificates Fee :		US ${{FeeForAdditional \| number: 2}}
Late Fee :		US ${{ReLateFee \| number: 2}}
Total :		US ${{TotalFee \| number: 2}}

Payment Information


	Credit Card Information

Card Number :	(no dash or space accepted)
CVV :
Expiration Date :

Billing Information

Required Fields

	Copy details from application
First Name :
Last Name :
Street :
City :
State/Province :
Zip/Postal Code :
Country :

The California Massage Therapy Council fees are NOT REFUNDABLE. The Application Fee expires in 12 months and the Background Check Fee expires in 6 months.

Your credit/debit card will be charged by The CALIFORNIA MASSAGE THERAPY COUNCIL. The CALIFORNIA MASSAGE THERAPY COUNCIL fees are NOT REFUNDABLE, PLEASE ENSURE THE ACCURACY OF YOUR INFORMATION.

Credit Card Processing

IMPORTANT: When you click Pay and Submit, you will be taken to a secure payment portal page.

Enter your payment information, and then click on the Pay Button.

After your payment is submitted,

YOU MUST CLICK ON THE CONTINUE BUTTON OR CAMTC WILL NOT RECEIVE YOUR APPLICATION, AND YOUR PAYMENT WILL BE REFUNDED.

Checklist

Yes

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California Massage Therapy Council
One Capitol Mall, Suite 800
Sacramento, CA 95814

Denial Information:
PSD Comment:
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