Massage Ordinance Background Check
Please complete all sections to provide personal background information for the massage ordinance application.
Business Name
*
Permit Number
*
First Name
*
Middle Name
Last Name
*
Alias
SSN or TIN
*
Date of Birth (DOB)
*
-
Month
-
Day
Year
Address
*
City
*
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
DC
AS
GU
MP
PR
VI
AA
AE
AP
ZIP (Five Digits)
*
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
State Where ID/DL Was Issued
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
DC
AS
GU
MP
PR
VI
AA
AE
AP
State ID/Driver's License #
*
Sex
*
Please Select
Male
Female
Race/Ethnicity
*
Please Select
Hispanic or Latino
White
Black or African American
Native Hawaiian or Other Pacific Islander
Asian
American Indian or Alaska Native
Two or More Races (Not Hispanic or Latino)
State Board License Number
*
State Board License Expiration Date
*
-
Month
-
Day
Year
Current Employee
Yes
Upload the massage license for the above employee.
*
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Please Select
Yes
No
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