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Permit Application for Person(s) Engaged in Off-Site Massage Therapy

Personal Information

Applicant

Have you ever been convicted of a felony or a crime involving moral turpitude, a crime involving controlled dangerous substances, or an offense involving sexual misconduct, or an offense involving the use of force or violence upon someone, or any other crime that would amount to a felony? If your answer is yes to any of the above questions explain in detail.

List all prior massage or similar business experience for the past ten (10) years and the City & State. If the applicant ever had a license or permit to perform massage therapy suspended or revoked please explain.

Authorization

I, the applicant, do hereby authorize the City of Moore, it`s agents or anyone designated by the City of Moore, to contact any source to verify the information supplied in this application.

Declaration

I, the applicant, do hereby authorize the City of Moore, it`s agents or anyone designated by the City of Moore to contact any source to verify the information supplied in this application.