Has the person in this Section been arrested for, convicted of, or pleaded guilty or entered a plea of nolo contendere within the past 10 years to a specified criminal activity (Sec. 22-301), or been found by a tribunal to have violated a state law or regulation governing the practice of massage therapy? Sec. 22-304(c)(9).
Eye Color
Sex
Previous Address 1
Criminal Record Exists?
Address
If Yes, Disclose The Jurisdiction In Which The Conviction And The Offense For Which Convicted And Circumstances Thereof
Previous Address 2
State
Height (ft/in)
Email
Title
Additional Owner Information
Date of Birth
Has the person in this Section been an owner, director, officer, partner, member, or shareholder of a massage establishment or spa establishment that has, in the previous five (5) years (and while the person was so related to the establishment) been found by a court to have been operating unlawfully, been enjoined by a court from engaging in conduct prohibited by law, been held in contempt of court for operating contrary to a court order, been declared by a court to be a nuisance, had its license to operate a massage establishment or a spa establishment revoked, or been subject to a court order requiring closure of the business or affirming revocation of any license required to operate the business? Sec. 22-304(c)(8).
Social Security #
Location
Date
% Owned
Has the person in this Section in the previous twelve (12) months resided with someone who has been an owner, director, officer, partner, member, or shareholder of a massage establishment or spa establishment that has, in the previous five (5) years (and while the person was so related to the establishment) been found by a court to have been operating unlawfully, been enjoined by a court from engaging in conduct prohibited by law, been held in contempt of court for operating contrary to a court order, been declared by a court to be a nuisance, had its license to operate a massage establishment or spa establishment revoked, or been subject to a court order requiring closure of the business or affirming revocation of any license required to operate the business?
Phone #
Name
Name
Resolution
Weight (lbs)
City
SSN #
Email
Employee Information
If YES, Please Explain
City
Title
If Other, Please Specify
Date of Birth
Address
ZIP
Employee Ever Convicted of a Crime?
Phone #
Name
State
Property Address:
Reference #:
Date Submitted:
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