Laserfiche WebLink
enteryilre <br />2synlfr.�edlt;5i <br />APPLICATION FOR MASSAGE THERAPIST CERTIFICATION/LICENSE <br />CITY OF CENTERVILLE <br />z <br />Date <br />MASSAGE LOCATION/ADDRESS I Nf)�evme Nlaa-- <br />N55c�3� t <br />HOURS/DAYS OF OPERATIO..:m <br />NAME OF APFLICANTe _, i j o rl 0 (' <br />(first) mihdle) ( st)- <br />Ce <br />DATE OF BIRTH HOME TELEPHONE ##: . <br />SCHOOL ATTENDED AND DEGREES RECEIVED: tenp <br />LIST QUALIFICATIONS TO PRACTICE MASSAGE:�Y1iS+�l rY111 (3S1C�rJP� [n $�Ccq P <br />LIST THREE CHART CTER REFERENCES (INCLUDE ADDRESS AND BTRTH DATE): <br />1 � jj.e�Se 4;a�l;ns -- <br />.1cace, 'Be,rge5cn/ e r , <br />AS APPLICANT EVER BEEN CONVICTED OF A CRIME, OTHER THAN A TRAFFIC VIOLATION'! <br />YES NO� <br />IF YES, PLEASE GIVE AN EXPLANATION ON A SEPARATE PIECE OF PAPER, INCLUDING TIME, PLACE AND <br />NATURE OF SUCH CRIME OR OFFENSE AND DISPOSITION THEREOF, <br />THE APPLICANT SHALL PROVIDE THE FOLLOWING INFORMATION: <br />A. EVIDENCE OF APPLICANT'S EDUCATION INCLUDING CONTINUING EDUCATION IF APPLICABLE. <br />B. EVIDENCE OF APPLICANT'S QUALIFICATIONS AND CHARACTER REFERENCES, <br />C. EVIDENCE IN THE FORM OF A CURRENT CERTIFICATE FROM A LICENSES PHYSICIAN <br />PRACTICING IN MINNESOTA INDICATING THAT SAID MASSAGE THERAPIST WAS EXAMINED <br />AND IS FREE OF ANY COMMUNICABLE DISEASE THAT WOULD DISQUALIFY THE APPLICANT <br />FROM ENGAGING IN THE PRACTIC OF MASSAGE, <br />A RENEWAL CERTIFICATE WILL BE REQUIRED EACH CALENDAR YEAR, ALONG WITH A PHYSICAL <br />EXAMINATION CERTIFICATE, COMPLETED APPLICATION AND RENEWAL FEE OF $50. APPLICANTS WILL <br />STRICTLY COMPLY WITH ALL REGULATIONS PROMULGATED BY THE CITY COUNCIL OF THE CITY OF <br />CENTERVILLE AND ALL ORDIANCES OF SAID MUNICIPALITY. <br />I hereby certify that I have read the foregoing auestions and that the answers to said questions are true <br />of my own knowledge. <br />SigFiature of Applicant ' <br />