Republic of the Philippines

Department of Health
Center for Health Development
Western Visayas

COMMITTEE OF EXAMINERS FOR MASSAGE THERAPIST (CEMT)

RENEWAL APPLICATION (LICENSE)
Control No. _______
NAME: ___________________________________________________________ _________
ADDRESS: _____________________________________________________ ____________
DATE OF BIRTH: __________ ______ AGE: ______ ______________
CONTACT NUMBERS: OFFICE: _______________ _______
RESIDENCE: _________________________________________ CEL#: ________ _______
OFFICE ADDRESS: ___________________________________________________ ______

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Supporting Documents: Date Submitted: ______________

____ MEDICAL CERTIFICATE ____ 1 pc 1x1 ID PICTURE

____ PTR (from LGU) ____ 2 pcs 2x2 ID PICTURE
____ RESIDENT CERTIFICATE ____ RENEWAL FEE RECEIPT /NUMBER
____ PROFESSIONAL IDENTIFICATION CARD
____ CMTE CERTIFICATION OF CREDIT UNITS EARNED
____ CERTIFICATE OF REGISTRATION (PHOTOCOPY)
____ BUSINESS PERMIT / CERTIFICATE OF EMPLOYMENT /
NOTARIZED LETTER IF NOT PRACTICING THE PROFESSION

(Signature)
Licensed Massage Therapist

Noted by:

_________________________
(Signature over printed name)
Program Coordinator

DOH-CHDWV-HPAC-FORM10-REV0