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<br />19. Have you had any previous massage therapist license that was <br />revoked, suspended, or not renewed? Yes _____ No <br /> <br />If yes, explain in detail: <br /> <br />20. <br /> <br />Have you ever made <br />license or similar <br />__Yes <br /> <br />~pplication for a massage therapist <br />activity and had such application denied? <br />NO <br /> <br />If yes, explain in detail: <br /> <br />I unQeratand that the information provided in this application <br />may be considered private or confidential data. I further <br />understand that I may not be required by law to provide such <br />information. The purpose of providing such information is to aid <br />the city of Little Canada in its determination on my application <br />for a permit. I aCknowledge that providing, or failing to <br />provide, such information may atfect the City'S determination on <br />my application. I understand this information will be made <br />available to the city of Little Canada, its city Council. agenda <br />and representatives, as well as the Minnesota Department of <br />Revenue, or any other person or entity authorized b~ law to <br />receive said intormation. I release the City of Little Canada <br />from any and all liability for it$ receipt and use of data <br />reoeived pursuant to this applioation. <br /> <br />, being first duly sworn, <br />Upon"his/her oath, deposes and says that he/she is the person who <br />has executed the above Personal Information Form, and that the <br />statements made therein are true of hiS/her own knOWledge and <br />beliet. <br /> <br />signature <br /> <br />Subscribed anct SWorn to before me this _____ day Of <br />19____. <br /> <br />Notary Public <br /> <br />County <br />My commission Expires ____ <br /> <br />]1 .~ <br /> <br />R,CbnQblCO '()lJ Vii'; <br /> <br />IinHlJIi() "11 III ,() lll() <br /> <br />0",1 lJ()1J 111-0'-:.1111.1 <br />