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<br /> <br />11>15. ~ <br /> <br />APPUCAnON PORMASSAGE TBEltAPIST CERTD'lCATIONILICENSE <br />CITY 01' CENTERVILLE <br /> <br />1I- ;JJ. -0(, <br />Date <br /> <br />MASSAGBLOCATION/ADDRESS ~\<A.\)\n ~\ roprG\.(,;\-c~ <br /> <br />HOURSIDAYSOFOPBRA11ON fll-~ ( . 1./- 7 <br /> <br />NAMEOFAPPLICANT LIsA KA~l.ln K:ese\horst. <br />(first) (1IIidcIIe) J' (last) <br />DATE OF BIR.m 1- J.S -(0 S" HOME 'lELEPBONB f#: ~..., --<..S-?> II( ~ '6 <br /> <br />SCHOOL ATI'ENDED ANDDBGRBESItECEIVBD: ~6h R~~~(\J ~j'",~~e... S~ )'00 \ ~ rntl~ ~ <br />1\ .J.. "r ~ .1 m '-11_ ..L.. p." 71to11l(J5c>Y) ~ J:. ~ lJ,so <br />L.~~tT~~ l..!..J(J.~~ II\O~~~ ~ f~ tnw ~/fI <br /> <br />usr QUAUFlCATIONS REQUIRED TO PRACl1CB MASSAGE: '1 ~ fwu.u,~ ~ O-",d Uw1d. ofl <br />~~~ v..\"Id. ~~ ~ b1 ~n'~ \)fcL.~~'~~. <br /> <br />USTTHRBB CHARACTHRRBFBRENCES ~rr AND JgTHDATE): Pc,.: ~ 000 <br />l\J(J.n~ ~h/\~-DOC5 7-"-$2. ~~ ~(O ,2.-70-1 f l.lS-l .t- J.j.illli .l,2-r-S3 <br />'<"Li~ ~~ ''''~P''y) ~l ~u{k.-rlil) ~ <br />, _ qlt.' ( - - 0 - LJ90- <br />HAS ~8EEN CONVICIED OF A CRIMB. arBER THAN A TRAFFIC VIOLADON? <br />YES NO ~ ~ - C.SI - 7f,'j -4l1T" <br /> <br />I~' (l)CA~n~t <br />. &.(\ \t.~\J, IIR.. m~~ <br /> <br /> <br />lP YES, PLEASE GIVB ANBXPLANA1ION ON A SEPARATE PIECE OF PAPER, JNa.UD1NG TJMB, PLACE AND <br />NA1URE OF SUCH CRJMB OR. OFFBNSB AND DISPOSmON THEREOF. <br /> <br />TUB APPUCANT SBAU. PllOVIDE TBB FOLLOWING INFORMATION: <br /> <br />A. EVIDENCE OF APPLICANTS EDUCA1ION INCLUDING CONTINUING EDUCATION lP APPLICABLE. <br />B. EVIDENCE OF APPLICANTS QUALIFlCA110NS AND CHARACI'ER RBFBRBNCES. . <br />C. EVIDENCE IN THE FORM OF A CURRENT CERTIFICAlE FROM A UCBNSES PHYSICIAN <br />PRAcnClNG IN MINNBSOrA INDICATING mAT SAm MASSAGE THERAPIST WAS EXAMJNBD <br />AND IS FREE OF ANY COMMUNICABLE DISEASE THAT WOULD DISQUALIFY THE APPLICANT <br />FROMBNGAGING INTBBPRACDC OFMASSAGB. <br /> <br />A RENEWAL CERTIFICATE WILL DB REQUIRED ~CH CALBNDAR YEAR, ALONG WITH A PHYSICAL <br />EXAMINATION CERTlPlCA'IB. COMPLB'IED APPLICA110N AND RENEWALFEB OF $50~ APPUCANTS WILL <br />STRICI'LY COMPLY Wl1H ALL REGULATIONS PROMULGATBD BY THE cnY COONeR. OF THE CITY OF <br />CEN'lERVILLE AND AlL ORDIANCES OF SAID MUNICIPALITY.. <br /> <br />I hereby certify that I have read the foregoing~. . as and that the BDSWeI'S to said questions are true <br />oI'my ownkDowlodae- . ~DJ'--1 <br /> <br />. . 0 Applicant <br /> <br />Subscribed BDCl swomto before me <br /> <br />j <br />