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<br />Mt:i<-2?-20~1 18:!,J2 <br /> <br />612 985 4499 P.02/04 <br /> <br />CITY OF LAKEVILLE <br />THERAPEUTIC MASSAGE PRACTITIONER <br />LICENSE APPLICATION <br />(Type or Print) <br /> <br />Applicant Name <br /> <br />First <br /> <br />Middle <br /> <br />Last <br /> <br />Home Address <br /> <br />SlreOt <br /> <br />CitY <br /> <br />Stale <br /> <br />Zip <br /> <br />Telephone Number (including area code) <br /> <br />Date of Birth _1_1_ <br /> <br />How long have you worked as a massage practldoner? <br /> <br />List place(s) of employment in this field for the past tive- (5) y.acs; include addresses and tel~holle <br />number., <br /> <br />LiSl your presem employer, address and telephone number: <br /> <br />liave you been licensed as a massage therapist in llI!other municipaHty? Yes_ No_ If yes, <br /> <br />Where <br /> <br />When <br /> <br />Have you ever been conviclet! of any felony. crime or violation d any city ordinance other than traffic <br />related? Yes No <br />If yes, please ~ele .tlte following: <br /> <br />Dale of arrest <br />Charge <br />Dale of convictlo:! <br /> <br />Municipality of arrest <br /> <br />Sentence received. <br /> <br />1/11Ml <br />