Contact Name Listed on General Business License Application*

Drivers License #*

State*

Weight*

Height*

Hair Color*

Eye Color*

Age*

Date of Birth (dd/mm/yyyy)

Place of Birth (City,State)

Type of Massage to be Administered*

Business, Occupation or Employment of Applicant for Three (3) Years Immediately Preceding Date of this Application:

Business or Occupation

Name of Employer or Self-Employed

Address of Employer

Date of Employment (From-To)

Business or Occupation

Name of Employer or Self-Employed

Address of Employer

Date of Employment (From-To)

Business or Occupation

Name of Employer or Self-Employed

Address of Employer

Date of Employment (From-To)

Name of School

Date of Graduation (dd/mm/yyyy)

Address of School

Diploma/Certification

Have you ever been convicted of a felony?*

Yes

No

Have you been convicted of any offense involving sexual misconduct with children, prostitution, soliciting for prostitution, pandering, keeping a place of prostitution or pimping?*

Yes

No

Have you been convicted of any criminal or city ordinance violations, forfeitures of bond, please of nolo contendere or stipulations of the facts except for minor traffic charges or those stated above?*

Yes

No

Have you been professionally reprimanded, penalized, or disciplined by any professional organization or group to which you belong?*

Yes

No

Have you had a massage therapy license or similar license revoked or suspended?*

Yes

No

If you answered yes to any of the above five (5)questions, state the offense, date, location, plea entered and penalty imposed.

Thank you. Please submit this application in addition to the General Business License Application.