MASSAGE THERAPIST
ORIGINAL RENEWAL
Will your business be located in your home? YES NO
1. Name of Applicant:
Last First Middle
2. Name of Business:
3. Residential Address:
Street City State Zip
4. Business Address:
Street City State Zip
5. Residential Phone Number:
6. Business Phone Number:
7. Date and Place of Birth:
Month Day Year City State
8. Name and Address of Massage School:
9. Date of Completion of Schooling:
10. Dates attended massage school:
Attach all that apply:
A. A certified copy of your birth certificate.
B. A small photograph of the applicant.
C. Proof of active membership in a Professional Massage Therapy Organization.
D. An original diploma or certificate of graduation from a professional level entry program accompanied by proof of completion of a minimum of 500 hours of in-classroom study or certification of successful completion of certification exam.
E. A signed Medical Report of a Negative TB test by a Medical Doctor of the Director of the Public Health Department.
F. Proof of Insurance in the amount of $1,000,000.00.
CONFIDENTIAL MEDICAL CERTIFICATE
This will certify that underwent a tuberculosis test on .
The above-named person is free of tuberculosis.
Physician
Date
OR:
Illinois Department of Public Health
Date
11. Social Security Number:
12. Driver's License Number:
13. a) Have you been convicted of any felony in the past ten (10) years?
Yes, No
b) Have you been convicted of any offense involving sexual misconduct within the past five (5) years? Yes, No
c) Have you been convicted of any misdemeanor within the past five (5) years?
Yes, No
d) Have you been Professionally reprimanded, penalized, or disciplined by any professional organization of group to which you belong in the past five (5) years?
Yes, No
e) Have you had a Massage Therapy License or similar license revoked or suspended in the past ten (10) years? Yes, No
If you answered "Yes", please explain.
14. List all previous addresses for the last ten (10) years immediately preceding the date of this application.
E. An applicant for a Massage Therapy Clinic or School shall submit the following information:
(see attached permit Applications)
a. Sole Proprietor
b. Partnerships
c. Corporations
(Ord. 00-08, passed 6-7-00)