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, . FOR POLlCE DEPARTMENT USE . Date of Application: _'-1_ . Fee: Reviewed Denied Approved CITY OF MINNETONKA PERSONAL SERVICE (MASSAGE) APPLICATION FOR A NEW LICENSE This application form requests information which may be classified as private or confidential under the Minnesota Data Practices Act. This information is required by State law or City ordinance. The information will be used to determine your eligibility for issuance of a license, permit, or identification card. Failure to provide the information will result in a denial of the license, permit, or identification card. Applicanfs Name: Maiden Name: ILm) IFni) (Full Middle N8ITI.) Residence Address: (Street NMIe} ICily) (Slale). IZl>C"') Place of Birth: Date of Birth: Phone: ICily,S"') Height: Weight: Color of Hair. Color of Eyes: Have you ever used an Alias? Yes_ No_ If yes, list name(s), dates and places used: arital Status: Married Employer. Employer's address: Single Divorced Date of Employment: Have you been convicted for any crime other than a traffic offense during the past year? Yes_ No_ If yes, explain: Have you ever held a Personal Service License in another community? Yes_ No_ If yes, where? Have you even been denied a Personal Service License in another community? Yes_ No_ If yes, where? Have you held a Personal Service License in Minnetonka within the last two years? Yes_ No_ PERSONAL INFORMATION U.S. Citizen Status: Yes_ No_ If naturalized, date and place: Sodal Security Number. Driver's License Number. Have. you had training and experience in performing massage service? Yes_ No If yes, specify the training and experience? ployment Background for the past five (5) years (list below starting with most recent employment): DATES EMPLOYERS POSITION HELD