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New Jersey Board of Massage and Bodywork Therapy

Change-of-Address


(as it appears on your license certificate) 
(as it appears on your license certificate) 
(i.e. CCxxxxxx, MZxxxxxx, DIxxxxxx) The two-letter prefix is found on your license certificate and precedes your license number.) 
(i.e. xx001200, xx089890, xx019980) The six-digit license number is found on your license certificate after the two-letter prefix.) 
 
 
 
 
 
 
 
 
(if not U.S.A.) 
IMPORTANT:
You MUST also complete the OLD address tab, and all applicable
NEW address tabs, before submitting your form.
 
(if applicable) 
 
 
 
 
(if not U.S.A.) 
NOTE: If your mailing address is a business or practice location, you must provide the business or practice name in order to ensure mail delivery.
 
(if applicable) 
 
 
 
 
(if not U.S.A.) 
NOTE: If your mailing address is a business or practice location, you must provide the business or practice name in order to ensure mail delivery.
 
 
 
 
 
(if not U.S.A.) 

  
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Last Modified: 8/14/2018 9:49 AM