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					Application Is hereby made to the City of Long Branch for a License to operate a Massage Establishment and or to perform massage services and the following statements are made to the end that said license may be granted
I
am

applying for a license to

check whichever applies
a

Operate

Massage Establishment

100 00

License Fee

Massage Services for a Licensed Massage Establishment 50 00 License Fee
Perform 1 2 3 4 Name of

Applicant

Current Address

City and State Applicants two 2 previous addresses prior to current address

From 5

To

From

To

Height
Color of

Weight Eyes
Color of Hair

6

Business

Occupation
date of

preceding
termination

this

Employment for three 3 years Immediately Include all dates and reasons for application
or

Note

Use other side If additional space Is

required

7

Massage

or

similar license

experience

8

Has license for above
reason

occupaHon been revoked
Yes

or

suspended In this

or

any

other area If yes state denial

No

and list any business

acHvlty

or

occupaHon subsequent to

9

Has

an

application for massage

or

similar business license No

ever

been denied

or any other area Yes If yes state reason and list any business denial

In this

acHvlty

or

occupaHon subsequent to

10

List all criminal convlcHons and

grounds therefor Including date

Note

Use other side If addIHonal space Is

required

List all EducaHon HIGH SCHOOL COLLEGE GRAD SCHOOL

12
a

In

compliance with license requirements you must submit the following
3 bonaflde

Written statement of three
are

City of Long Branch residents stating

that you b

considered of

good moral character
age of 18 years
x

Written Proof that you Two 2 current

are over the

c

photographs

at least 2

2

stating that within the last 30 days prior hereto you have been examined and found to be free of any contagious or communicable disease
d Doctors note

diploma of certificate of graduation from a school accredited by the or Association the International and American Massage Therapy Federation Inc Myomassethlscs
e

A

NOTE
a

A license will be denied if

All

requirements described herein

are

not met

b
c

If It appears that the If
a

applicant has deliberately falsified this application
record of conviction of
a

applicant has turpitude

felony

or

a

crime of moral

Signature of Applicant

Date