RIVERSIDE POLICE DEPARTMENT
MASSAGE ESTABLISHMENT
EMPLOYEE INFORMATION SHEET
Applicant's
Name:
List any and all names, nicknames or aliases you have used in the past:
(Last)
(First)
(Middle)
Date of Birth
Home Address
City
State
Zip
Home Telephone # Cell Phone #
State of Issuance:Driver's License or Identification Number:
California Massage Therapy Council Certificate (CAMTC) Number:
Exp. Date:
Are you an Independent contractor? If "Yes," attach a copy of your business tax license.
NoYes
(Business Name)
Current employment location:
Business Telephone Number:
Zip
State
City
Business Street Address
I declare under penalty of perjury under the laws of the State of California that the above information I
am submitting is true and correct.
Applicant's Name (Print)
Applicant Signature Date
This Section Will Be Completed by Riverside Police Department
* This application must include original certificate and permit card issued by the California
Massage Therapy Council (CAMTC) along with California drivers license or California issued
ID. Copies will be made. Renew Annually. (Review Riverside Municipal Code (RMC) 5.52.110E
Registration for State Certificate Holders.
ORIGINAL CERTIFICATE MUST BE POSTED WHILE WORKING.
Reviewed by:
Police Department Employee Only
Title
