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Business License 38250 Sierra Highway Palmdale, CA 93550 661/247-8384 661/267-5434 [EMAIL REDACTED] [EMAIL REDACTED] MASSAGE TECHNICIAN PERMIT APPLICATION This Application is for (check one) New Permit Annual Renewal Legal Name of Applicant: (List any other name used by the applicant) Home Address: Telephone Number and Email: Driver’s License and Date of Birth: Social Security Number: Business Name: Business Address: Business Telephone Number: (If applying for more than one location, list all business names, addresses and telephone numbers) All previous addresses of the applicant for the last 10 years: The applicant’s age, height, weight, sex, color of eyes and hair, and date of birth: The employment history or experience of the applicant in the massage or similar business for the last 10 years immediately preceding the date of application, including but not limited to, the massage or similar business history and experience in this city or any other city or state: List any other permit or license as a massage technician issued by an agency, board, city, county, territory, or state; the date of issuance of that permit or license, and whether the permit or license was denied, revoked or suspended, and the reason therefor. Include the business activity or occupation engaged in by the applicant subsequent to any suspension or revocation: ---PAGE BREAK--- Business License 38250 Sierra Highway Palmdale, CA 93550 661/247-8384 661/267-5434 [EMAIL REDACTED] [EMAIL REDACTED] All criminal convictions, including ordinance violations and pleas of nolo contendre, within the last 10 years, including those dismissed or expunged pursuant to Penal Code Section 1203.4, but excluding traffic violations, and a statement as to the date and place of each such conviction and reason therefor: Documentation of your experience as a practicing massage technician: New applicants please submit the following: 1. Copy of Certificate of graduation from a recognized school of massage. 2. Proof of membership in a “qualified massage association” which has a minimum education requirement of 500 hours of education and training as defined in Section 5.04.560.A. 3. LASD License Detail Personal Information form. 4. Livescan fingerprinting and photo will be taken at the City of Palmdale’s Human Resources Department. Renewing applicants please submit the following: 1. Proof of current Insurance 2. Livescan fingerprinting and photo to be taken at Human Resources I authorize the City, its agents and employees, to seek verification of all information contained in this application and I declare under penalties of perjury that all information contained in the application is true and correct to the best of my knowledge and belief and that all provisions of the Municipal Code Section of 5.04.560 will be adhered to. Signature of Applicant Date OFFICE USE ONLY Recommend ( ) Not Recommended ( ) Los Angeles County Sheriff’s Department: Signature Date City Council Approval or Denial: Date Planning Manager: Signature Date