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<br /> <br />",' f~ <br />IJf~t <br /> <br />APPLICATION FOR MASSAGE THERAPIST CIQlTmCATIONlLlCENSE <br />CITY OF CENTERVILLE <br /> <br />It-lO-C)? <br />Date <br /> <br />MASSAGBLOCATIONlADDRESS 7Qz,c 2-D ~ Ave. 5 1.1J"f<-.I 05 <br />OOuRsmAYSOFOPERATION MOIIJ - '?UVl q4-H/ ,fCJ 'IfM <br />NAME OF APPLICANT W ~ (I iIJ.fA/I '"\ ~ ~ Ie r v't <br />, ~)' ~ ~)' <br />DATE OF BIRTH 11- UJ - If..ga ElOME TELBPHONB #: bIZ - 1<37- '10 'SS <br />SCHOOL ATl'ENDED AND DEGREES RECBIVED: /II1lVl/ll e ~(..e.. ~ "f (()-F BJ"I1eJ's <br />avd q/o~ ~I/~~ ./1M5~Y T/;,f~ [Xf/~MA.. <br />UST QUALIFICATIONS RBQUIRED TO PRACflCE MASSAGE: t Yr' M~ c;~ ~ L '"'f1' ~~Y <br />f- . 3Z ~" ' <br />tl fJe,)J.y('ovr+ Ct.< ,'ropf77C..f,C J"C1 ~ M 1'1,;,"~SO Jl~ "'- ' .II. J <br />IJST 1'HREE CHARACI'ERREFElU!NCES (lNa.u.oB AND BlR.THDATE):~ W14 ~~h <br />(YAir JGl/L fg;f -770- m~ DJR 5-tj-/~6f '!)1P~,,;p f1.1';' ~t ut;.e 6fZ-ZZl-<:Ja83 <br />l.e;I/'e cAec-M&1.K. 1.&4 plMO iGI-77b- 71'" 1):)3 ~-Z-I-/~67 008 <br />HAS APPLICANT EVER. BEEN ~CIBD OF A CRlMB. OTHER. 'I"H'AN A TRAFFIC VIOLATION? IO-l~- ~ <br />YES NO-A-. <br />lFYES. PLEASE GIVE ANEXPLANATION ON A SEPARATE PIECB OF PAPER, INa.UDING TIME. PLACE AND <br />NATURE OF SUCH CRIMB OR OFFENSE AND DISPOSlTIONTHEREOF. <br /> <br />Ce,,",~i(1 L Nt fV <br />65' oJ8 <br /> <br /> <br />TBB APPLICANT SHALL PROVIDE THE FOLLOWING INFORMATION: <br />A. EVIDENCE OF APPLICANTS EDUCATION INCLUDING CONTINUING EDUCATION IF APPLICABLE. <br />B. EVIDENCE OF APPLICANTS QUALIFICATIONS AND CHARACl'ER.RBFBRENCBS. <br />C. BVlDBNCB IN TIm FORM OF A CURRENT CERTIFICATE FROM A LiCENSES PHYSICIAN <br />PRACflCING IN ~A lNDICATING mAT SAID MASSAGE TBBRAPIST WAS BXAMINBD <br />AND IS FREE OF ANY COMMUNICABLE DISEASE mAT WOULD DISQUALIFY THE APPLICAN'I <br />FROM ENGAGING IN 1HE PRACflC OF MASSAGE. <br />A RENEWAL CERTIFICATE WIlL BE REQUIRED EACH CALENDAR YEAR, 'ALONG wrm A PHYSICAl <br />EXAMINATION CERTIFICATE,. COMP.LE'IED APPLICATION AND RENEWAL FEE OF $>>. APPLICANTS WILI. <br />STRIcny COMPLY WITH AU. REGULATIONS PROMULGATED BY THB CITY COUNen. OF THE CITY OF <br />CENTERWLE AND AIL ORDIANCBS OF SAID MUNICIPALITY. <br />I hereby certify that I have read the foregoing questions and that the answers to said questions are tIUe <br />ofmy """lmowfedse. ~ ~ <br />~ of Applicant <br /> <br /> <br />Subscribed and sworn to before me ~ - <br /> <br /> <br />j' r;2., ~ <br />~__ _____ U II <br />