Fillable Supervising Faculty Member Certication (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Supervising Faculty Member Certication (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
New Jersey Board of Massage and Bodywork Therapy
124 Halsey Street, 6th Floor, P.O. Box 47032
Newark NJ 07102
(973) 504-6520
Supervising Faculty Member Certication
I,_______________________________________________,amthesupervisingfacultymemberat
________________________________________,___________________________________________

Nameofschool

Addressofschool
PursuanttotherequirementofN.J.A.C.13:37A-2.1(d)(5),IhavesupervisedApplicant
________________________________________________foratleast100hoursofclinicalpracticefrom

Applicant’sname
_________________________________________to_______________________________________.
I am licensed to practice massage and bodywork therapy in New Jersey and my license number is
__________________________________________.
I am not licensed to practice massage and bodywork therapy in New Jersey, however, I am legally
authorized to perform massage and bodywork in the State in which the school exists and my license
numberis___________________________________.
Certication in Lieu of Afdavit:
Icertifythattheforegoingstatementsmadebymearetrueandcomplete.Iamawarethatifanyofthe
foregoingstatementsprovidedarewillfullyfalse,Iamsubjecttopunishment.
_____________________________ _________________________________________

Date Signatureofsupervisingfacultymember

(Stamped signature will not be accepted.)
Closed Schools Only
Ifthemassageschoolisnowclosed,thecurrentcustodianofrecordsfortheclosedschoolistocertifythat
thecompleted100hoursofclinicalpracticewhichwassupervisedbyafacultymemberisinconformance
withtherequirementsofN.J.A.C.13:37A-2.1(d)(5).Ifthereareanydecienciesregardingaparticular
student/applicant’sclinicalpractice,thecustodianofrecordswillspecifythenatureofthedeciencies
withinthecertication.
_____________________________ _________________________________________

Date Signaturefromcustodianofrecords

(Stamped signature will not be accepted
.
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Supervising Faculty Member Certication (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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