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<br /> <br /> <br /> <br /> <br /> <br />APPLICATION FOR MASSAGE THERAPIST CERTIFICATION/LICENSE <br />CITY OF CENTERVILLE <br /> <br /> <br />Date <br /> <br />MASSAGE LOCATION/ADDRESS <br /> <br />HOURS/DAYS OF OPERATION <br /> <br />NAME OF APPLICANT <br /> (first) (middle) (last) <br /> <br />DATE OF BIRTH HOME TELEPHONE #: <br /> <br />SCHOOL ATTENDED AND DEGREES RECEIVED: <br /> <br /> <br /> <br />LIST QUALIFICATIONS REQUIRED TO PRACTICE MASSAGE: <br /> <br /> <br /> <br />LIST THREE CHARACTER REFERENCES (INCLUDE ADDRESS AND BIRTH DATE): <br /> <br /> <br /> <br />HAS APPLICANT EVER BEEN CONVICTED OF A CRIME, OTHER THAN A TRAFFIC VIOLATION? <br /> <br />YES NO <br /> <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 /> <br />THE APPLICANT SHALL PROVIDE THE FOLLOWING INFORMATION: <br /> <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 /> <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 /> <br />I hereby certify that I have read the foregoing questions and that the answers to said questions are true <br />of my own knowledge. <br /> <br /> Signature of Applicant <br /> <br /> <br />Subscribed and sworn to before me <br />