New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Massage and Bodywork Therapy
124 Halsey Street, 6th Floor, P.O. Box 45048
Newark, New Jersey 07101
(973) 504-6520
Application to Reinstate a Business License
Business Full Name: __________________________________________________________________________
Expired Registration Number: ___________________________________________
Owner/Operator Name: ________________________________________________________________________
1. Do you currently employ another massage and bodywork therapist at this location? Yes No
2. Do you intend to employ another massage and bodywork therapist at this location? Yes No
Public Address of Record:
Street: ____________________________________________________________________________________
City: __________________________ State: _________ Zip code: _____________ County: __________
Telephone number: (_____) _________________ Email: ____________________________________________
Mailing Address:
Street: ____________________________________________________________________________________
City: __________________________ State: _________ Zip code: _____________ County: __________
Telephone number: (_____) _________________ Email: ____________________________________________
Submit a written response to the Board, detailing whether the business has been operational since its expired registration
date and explain the types of services that have been provided.
Criminal Background Questions
1. Has the owner/operator ever been summoned; arrested; taken into custody; indicted; tried; charged with; admitted
into pre-trial intervention (P.T.I.); or pled guilty to any violation of law, ordinance, felony, misdemeanor or
disorderly persons offense, in New Jersey, any other state, the District of Columbia or in any jurisdiction?
(Parking or speeding violations need not be disclosed, but motor vehicle violations such as driving while impaired
or intoxicated must be.)
Yes No
2. Has the owner/operator ever been convicted of any crime or offense under any circumstances?
Yes No
3. Has there been a change in the ownership of this shop since the registration expired? Yes No
4. Has there been a change in the location of this facility since registration expired? Yes No
Payment for business license - $150 made payable in check or money order to:
New Jersey Board of Massage and Bodywork Therapy
Attestation
By making this application to the Board for registration, I certify that the business employs, and will employ in the
future, only massage and bodywork therapists who are licensed by the Board to provide massage and bodywork
services. I certify that the forgoing statements are true. I am aware that if any of the forgoing statements made by me
are willfully false, my business registration may be suspended or revoked.
___________________________________________________ _________________________
Signature Date
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