Wisconsin Department of Safety and Professional Services
Office Location: 4822 Madison Yards Way LicensE Portal: https://license.wi.gov/
Madison, WI 53705 Email: dsps@wisconsin.gov
Phone Number: (608) 266-2112 Website: http://dsps.wi.gov
MASSAGE THERAPY AND BODYWORK THERAPY CREDENTIALING BOARD
MASSAGE THERAPIST OR BODYWORK THERAPY PROGRAM CURRICULUM
APPLICANT: Complete this section and submit to certifying school for completion. Form must be returned directly from the
school to the Department. Please note: If your school is not Wisconsin Educational Approval Program (EAP) approved, or is not a
Wisconsin Technical College, you must ask school to submit official transcripts with this form.
Last Name First Name MI Former / Maiden Name(s)
Address (number/ street) (city) (state) (zip code)
Social Security Number (voluntary,
Date of Birth for school use in locating your records) Application Number
/ / - -
ATTESTATION OF APPLICANT: I declare that I am the person referred to on this form and that all information required to be completed by me (the
applicant for a credential), is complete and accurate to the best of my knowledge and belief. Furthermore, I declare that after completing the information that
was required by me (and only that information) the form was forwarded to the relevant third-party for completion of the information asked of them. I also
declare that to the best of my knowledge the completed form was provided to the Department of Safety and Professional Services by the relevant third-party
(and not by me, the applicant). Finally, I declare that I understand that failure to provide the requested information, making any materially false statement
and/or giving any materially false information in connection with my application for a credential may result in credential application processing delays;
denial, revocation, suspension, or limitation of my credential; or any combination thereof; or such other penalties as may be provided by law. By signing
below, I am signifying that I have read and understand the above declarations. I hereby authorize the school named below to provide the Department with
the information requested below.
/ /
Applicant Signature (If unable to provide a digital signature, print and sign form.) Date
CERTIFYING SCHOOL: Complete this section for the above-named applicant and return directly to the Department using the
LicensE Third-Party* Upload Portal at license.wi.gov. You will need the application number shown above. (*For form completion
purposes, the term “Third-Party” refers to any non-applicant or non-DSPS individual or entity submitting required documentation in
support of a credential application.)
Enter the number of classroom hours of study applicant has completed in the seven (7) areas listed below. The total must be at least 600 hours.
Hours
Anatomy, Physiology, Pathology, Kinesiology (125 hours required)
Business, Law, and Ethics (50 hours required)
Check if applicable. Includes at least 6 classroom hours in the laws of the State of Wisconsin and rules of the
Department relating to the practice of massage therapy or bodywork.
Wisconsin State Laws and Administrative Rules governing Massage Therapy and Bodywork Therapy
Check if applicable. Student has taken and passed the Wisconsin State Law and Administrative Rules examination.
Massage Therapy or Bodywork Theory, Technique and Practice (300 required)
Student Clinic (20 hours required)
Adult CPR/AED and Standard First Aid (5 hours required)
Additional Course Offerings Meeting Massage Therapy or Bodywork Course Objectives (Required) _____________
Total Hours Completed (must equal 600 hours or more)
AFFIDAVIT: I attest to the fact that the above-named applicant has completed at least 600 hours of classroom study, as indicated above, in
a training program in massage therapy or bodywork therapy.
School Name
Schl Address
Continued on next page.
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Committed to Equal Opportunity in Employment and Licensing
Wisconsin Department of Safety and Professional Services
Was school EAP approved at the time the applicant completed the course of study? Yes No
Is this school a Wisconsin Technical College? Yes No
Is this school accredited? Yes No
Name of the accrediting body at the time applicant completed course of instruction: _________________________________________
Coursework Completion Date: / /
ATTESTATION OF THIRD-PARTY PROVIDING INFORMATION RELATED TO APPLICANT: I declare, on behalf of the third-party asked to
provide information related to the applicant identified on this form, that the information provided is true and correct to the best of my knowledge and belief.
I further declare that after completing the form I, or other third-party staff, will provide the completed form directly to the Wisconsin Department of Safety
and Professional Services for review. By signing below, I am signifying that I have read, understand, and have complied with the above declarations.
/ /
Signature of Dean or Department Head Date
(If unable to provide a digital signature, please print and sign form.)
- - Ext___________
Printed Name Phone
Title
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Wis. Stat. ch. 460 Page 2 of 2
Committed to Equal Opportunity in Employment and Licensing
