Form Application For Permit To Operate Massage Establishment Or Outcall Massage Service

APPLICATION FOR PERMIT TO OPERATE MASSAGE ESTABLISHMENT

OR OUTCALL MASSAGE SERVICE

UNDER CHAPTER 626, SLCRO

Name of Sole Owner or Partners_______________________________________________________________________________________________

Name of Massage Establishment________________________________________________________________________________________________

Address_____________________________________________________________________________________ Phone #_______________________

Street

City

State

Zip Code

Applicant must provide the following information (if Partnership, EACH partner). Make a xerox copy for EACH partner to complete #'s 1-8

below):

1. Full Name_______________________________________________________________________________________________________________

First

Middle Initial

Last

2. Present Address___________________________________________________________________________ Phone #_______________________

Street

City

State

Zip Code

3. Two Previous Addresses:

________________________________________________________________________________________ Dates:_____________________________

Street

City

State

Zip Code

_______________________________________________________________________________________ Dates:_____________________________

Street

City

State

Zip Code

4. Date of Birth_________________________________ Height__________________________ Weight____________________ Sex_____________

Social Security #_________________________________ Color of Hair_____________________________ Color of Eyes_____________________

5. Businesses, Occupations or Employments for the three (3) years immediately preceding date of application (if additional space is needed, use the back

of this page or attach additional sheets):

___________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________

6. Previous experience in the operation of a Massage Establishment, Outcall Massage Service or similar business or occupation (if additional space is

needed, use the back of this page or attach additional sheets):

___________________________________________________________________________________________________________________________

7. Have you ever had a permit to operate a Massage Establishment or Outcall Massage Service that was revoked or suspended in this or any other State?

Yes_______ No_______

If Yes, give details (if additional space is needed use the back of this page or attach additional sheets):

___________________________________________________________________________________________________________________________

8. Have you ever been convicted for violation of any criminal Statutes or Ordinances other than minor traffic violations? Yes_______ No________

If yes, give details (if additional space is needed use the back of this page or attach additional sheets):

___________________________________________________________________________________________________________________________

I do solemnly swear that the information contained in this application or incorporated here by reference is true, correct and complete to the best of

my knowledge.

___________________________________________

Signature of Individual

Subscribed and sworn to before me this _______ day of _____________________________, 19____________

My Commission Expires:___________________________ __________________________________________

Notary Public

REVL7.PDF

REVISED 7-21-00

Page 1 of 3

Form Application For Permit To Operate Massage Establishment Or Outcall Massage Service - 2000

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