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<br />II!R-06-01 MON' <br />~'1L.. L. l . <br /> <br />:56 PM CTY OF FOREST LAKE <br /> <br />FAX 10 651 464 4968 <br /> <br />J' <br /> <br />. <br /> <br />RENEWAL APPLICATION <br />FOR MASSAGE THERAPIST CERTIFICATIONILICENSE <br />IN THE CITY OF FOREST LAKE <br />ORDlNANCE 448 <br /> <br />RENEWAL YEAit <br /> <br />MASSAGE LOCATION/ADDRESS <br />HOUR.S!DA YS Of' OPERATION <br /> <br />NAME OF APPUCANT <br /> <br />(&;.1) <br /> <br />[milWle) <br />HOME 1ELEPH:ONE #: <br /> <br />(lMt) <br /> <br />OATS OF BmTH <br /> <br />SCKOOL A ITfNDSO AND DBGREES RECEIVED: <br /> <br />LIST QUALlFICA TIONS REQUlREO 1'0 PRACTICE: MASSAGE: <br /> <br />LIST TWO (2) CHARACTER UPElWNCES WHO RESltlE IN W ASHlNOTON COUNTY: NA."iES, <br />ADDRESS 4: PA J1! 01' BIRTH <br /> <br />HAS APPLICANT EVER !l!U!N CONVICTED Of A CRIME. OTHER THAN A l'RAffiC <br />VIOLATION'! ~YES ~O <br />IF YES, PLEASE GIVE AN EXPLANA nOl" ON A SEPAAATI! PIECE OF PAPER. INCLtJDlNO <br />TIME. PlACE Al'ID NATURE OF SUCH CRIME OR OI'n.NSl! AND IllSPOSrnON nmREOF. <br /> <br />THE APPUCANT SHALL PROVIDE THE fOLLOWING INFORMATION: <br /> <br />A. BVIDI!NCE OF APPLICANTS' E!lUCA'l'lON INCLtiDINO CONrnlUlNO EDUCATION rF <br />APPLICABLE. <br />B, EVIDENCS OP APPLiCANtS' QUALlJ'lCAnOl"s AND Cw.RACTER REFBRE.'>ICES. <br />C, BVIDENCE IN TIm FOaM OP A CURRENT CERTlFICA'P> PROM A LICENSED <br />PH'iSICAN PRACT1CING IN MINNESOTA INDICATING THAT SAlt) MASSAOE <br />~[ST WAS E:XAMINW AND ISPRl'.!! OF Al'i'Y COMMt.1NICABLE DlSEASl> THAT <br />WOULD DISQU.u.lF'Y THE APPLlCA.'>IT PROM ENGAGING IN nm PRACIlC OF <br />MASSAGE. <br /> <br />A RENEWAl CERTIFICATE WILL aE R,EQUlREJ) EACH CALENDAR YEAR, ALONG WIlli A <br />PHYSICAL ID<AMlNATION CIlRTIFlCAT!, COMPLETED APPUCA TlON AND Rm.'BW AI. FEE <br />OF $~O.OO. APPLICANTS WlLL smCTL Y COMPLY WITH ALL REGULATIONS <br />PROMULGATED ay THE CITY COUNCil. OF FOR1!ST LAX:S AND ALL ORDINANC:SS OF SAID <br />MUNICIPLATY, <br /> <br />P, 4 <br />