CITY OF CARBONDALE, ILLINOIS APPLICATION FOR MASSAGE THERAPIST LICENSE

Transcription

1 CITY OF CARBONDALE, ILLINOIS APPLICATION FOR MASSAGE THERAPIST LICENSE The following information must be submitted for any person wishing to become licensed as a Massage Therapist or who engages in the practice of massage within the City of Carbondale: Business Address where massage is to be practiced: Business Phone Number: Applicant's Name Street Address P.O. Box City/State/Zip Code Residential phone number Social Security Number Date of Birth* *Please attach photocopy of birth certificate or other written proof that you are at least 18 years old. Driver's License Number State of Issuance Sex Height Weight Hair color Eye Color List all residential addresses for the past three (3) years: List business, occupation and/or employment for the last three years immediately preceding the date of this application:

2 List massage and/or similar business history. If you have previously had a massage establishment, massage therapy or similar license revoked, denied or suspended in this city or in any other city or state, please state the date, the reason for the revocation, denial or suspension, and the business activity or occupation subsequent to such action of suspension or revocation: Have you ever been convicted of, pleaded nolo contendere to, or suffered a forfeiture on a bond charge of committing any crime, including city ordinance violations, except minor traffic violations? No Yes. If yes, please provide a statement giving the place and the court in which such conviction plea or forfeiture was had, the specific charge under which the conviction plea or forfeiture was obtained, and the sentence imposed as a result thereof Please provide the name, address and phone number of at least three (3) persons over the age of eighteen (18) other than a relative or business associate who has known you for at least three years prior to the date of this application. These persons will serve as character references. Please answer the following questions: 1. Are you at least 18 years old? yes no 2. Are you addicted to intoxicants, dangerous drugs or narcotics? yes no 3. Have you been convicted of a felony? yes no

3 If yes, please provide details: 4. Have you ever been convicted of an offense involving sexual misconduct with children, pimping, pandering, prostitution, assignation, solicitation, keeping a place of prostitution, larceny, robbery, assault with a dangerous weapon, any crime involving serious physical violence to another, sexual misconduct, or any other offense opposed to decency and morality? yes no. If, yes, please provide details: 5. Do you have an outstanding debt owed the City? yes no If yes, please describe: 6. Have you had a massage business, massage therapist, or similar license denied, revoked, or suspended for any of the above causes by the City or any other state or local agency within five (5) years prior to the date of this application? yes no If yes, please provide details: Use this checklist to assure you have attached the following required documents: ( ) One Recent photograph (head size must fit on license) ( ) NEW LICENSES ONLY: Fingerprints (may be obtained at your local police department or transferred from a prior license application) ( ) Written proof of a valid and current Cardio-Pulmonary Resuscitation (CPR) Certification ( ) Written statement from a licensed physician which states that this applicant has been examined and is either free from any contagious and/or communicable disease or is incapable of communication any such disease to others by close physical contact. For this purpose, a communicable disease is as defined by the Illinois Department of Public Health in Circular 5000, which constitute part of the rules and regulations promulgated by said Department pursuant to the authority of the Public Health Act of the State of Illinois (20 ILCS 2305/2). ( ) NEW LICENSES ONLY: Non-refundable filing fee of $50.00 (Check payable to City of Carbondale). ( ) RENEWAL LICENSES ONLY: No fee required as long as renewal application is submitted prior to the 31st day of March prior to the termination of an existing license. However, if an existing Massage Therapist License expires, is revoked, suspended or voluntarily surrendered, the application for a second or subsequent license must be submitted with the $50.00 non-refundable filing fee. NEW LICENSES ONLY: Please attach the following: ( ) Written proof (diploma, certification, etc.) of graduation or completion of a professional level entry program which consists of 500 hours or more of inclassroom study and 100 hours or more of clinical experience in a "recognized

4 school". The term "Recognized Schools" shall be construed and deemed to mean any school which meets any one or more of the following requirements:

5 1. A state-approved school operating according to state regulations which has a current license, approval, accreditation and/or certification from the state in which it is located and provides an entry-level massage training program of a minimum of 500 hours of in-class work, and 100 hours of clinical training, which program shall include anatomy and physiology, kinesiology, ethics, pathology, contraindications and clinical experience, or 2. A massage school program accredited/approved by the Commission on Massage Training/Approval & Accreditation (COMTAA), a current list of which can be obtained through the COMTAA Manager, 820 Davis Street, Suite #100, Evanston, IL , (708) Schools offering correspondence courses and not requiring actual class attendance shall not be deemed "recognized schools". All course work for hours credit shall be completed under the physical supervision of faculty. OR ( ) Written proof (diploma, certification, etc.) of having passed the National Certification Examination for Therapeutic Massage and Bodywork (NCETMB), administered by the National Certification Program for Therapeutic Massage & Bodywork, which is approved by the National Organization for Competency Assurance (NOCA); OR ( ) Written proof of having passed any other examination exhibiting proficiency in Massage Therapy/Bodywork approved by a state or federal certifying agency. ****************************************************************************** STATE OF ILLINOIS ) COUNTY OF JACKSON ) APPLICANT AUTHORIZATION AND CERTIFICATION By my signature below, I hereby authorize the City of Carbondale, its agents and employees, to seek information and conduct an investigation into the truth of the statements set forth in this application and accompanying documents. Under penalty of perjury, I hereby certify that the foregoing and accompanying information contained in this application is true and correct. Dated Applicant's Signature