Form Application For Permit To Operate Massage Establishment Or Outcall Massage Service - 2000 Page 2
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3List the requested information on each Masseur or Masseuse who is or will be employed in said Establishment or engage in Outcall Massage Service
and show how each is paid. If an independent Contractor, furnish copy of written agreements wherein the terms of such status are set forth and show
the amounts of money paid or to be paid and method of computation (if additional space is needed, make a xerox copy of this page):
Name_____________________________________________________________________________________________________________________
First
Middle Initial
Last
Address________________________________________________________________________________________ Phone #____________________
Date of Birth___________________________ Height_____________________ Weight_________________________ Sex_____________________
Social Security #_______________________________________________ Color of Hair_____________________ Color of Eyes________________
Straight Salary $____________________________________ Commission $____________________________ Ind. Contractor___________________
Name_____________________________________________________________________________________________________________________
First
Middle Initial
Last
Address________________________________________________________________________________________ Phone #____________________
Date of Birth___________________________ Height_____________________ Weight_________________________ Sex_____________________
Social Security #_______________________________________________ Color of Hair_____________________ Color of Eyes________________
Straight Salary $____________________________________ Commission $____________________________ Ind. Contractor___________________
Name_____________________________________________________________________________________________________________________
First
Middle Initial
Last
Address________________________________________________________________________________________ Phone #____________________
Date of Birth___________________________ Height_____________________ Weight_________________________ Sex_____________________
Social Security #_______________________________________________ Color of Hair_____________________ Color of Eyes________________
Straight Salary $____________________________________ Commission $____________________________ Ind. Contractor___________________
Name_____________________________________________________________________________________________________________________
First
Middle Initial
Last
Address________________________________________________________________________________________ Phone #____________________
Date of Birth___________________________ Height_____________________ Weight_________________________ Sex_____________________
Social Security #_______________________________________________ Color of Hair_____________________ Color of Eyes________________
Straight Salary $____________________________________ Commission $____________________________ Ind. Contractor___________________
Name_____________________________________________________________________________________________________________________
First
Middle Initial
Last
Address________________________________________________________________________________________ Phone #____________________
Date of Birth___________________________ Height_____________________ Weight_________________________ Sex_____________________
Social Security #_______________________________________________ Color of Hair_____________________ Color of Eyes________________
Straight Salary $____________________________________ Commission $____________________________ Ind. Contractor___________________
Name_____________________________________________________________________________________________________________________
First
Middle Initial
Last
Address________________________________________________________________________________________ Phone #____________________
Date of Birth___________________________ Height_____________________ Weight_________________________ Sex_____________________
Social Security #_______________________________________________ Color of Hair_____________________ Color of Eyes________________
Straight Salary $____________________________________ Commission $____________________________ Ind. Contractor___________________
REVL7.PDF
REVISED 7-21-00
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