LARA/BPL-MASSAGECURR (2/2020)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status, disability,
or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
Telephone: (517) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
CERTIFICATION OF COMPLETION OF MASSAGE THERAPY SUPERVISED CURRICULUM
Authority: 1978 PA 368
Section of Form to be Completed by Applicant:
Date of Birth (MM/DD/YYYY)
List any other name or alias by which you have ever been known, including maiden name, if applicable
Name of Educational Institution/Program
Street Address of Educational Institution/Program
Remainder of Form to be Completed by the Program Director
CERTIFICATION AND SIGNATURE
I certify the applicant named above attended the educational institution noted from ________________________________
(Month/Day/Year)
to _____________________________________.
(Month/Day/Year Completed)
I certify the applicant has successfully completed a supervised curriculum that satisfies the requirements of the Administrative Rules and Public Health Code as
indicated below (check appropriate box):
If the applicant is or was enrolled in school before August 1, 2017, 500 hours of coursework that satisfies the requirements of R 338.722(1) and MCL
333.17959 of the Public Health Code.
OR
If the applicant is or was enrolled in school on or after August 1, 2017 but before January 10, 2020, 625 hours of coursework that satisfies the
requirements of R 338.722(1) and MCL 333.17959 of the Public Health Code.
OR
If the applicant enrolled in school on or after January 10, 2020, 625 hours of coursework that satisfies the requirements of R 338.722(2), R 338.726
and MCL 333.17959 of the Public Health Code.
I certify under penalty of perjury the above information is true and complete.
_________________________________________________ ____________________________________________
Signature of Program Director Date
_________________________________________________
Name of Program/School (Seal) If academic institution has no seal, please indicate.
