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FOR POLICE OEPARTNlENT USE . Date of Application: _'_'_ . 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. Applicanrs Name: Maiden Name: (Lull (Fnt) (Full r.tiddle NMMI) Residence Address: (SIrHI N.me) (c.,.) (5") (ZlpCode) Place of Birth: Date of Birth: Phone: (City, Stille' 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: alital Status: Married Employer: Employer's address: Have you been convicted for any clime other than a traffic offense duling the past year? Yes_ No_ Single Divorced Date of Employment: If yes, explain: Have you ever held a Personal Service License in anolher 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: Social Security Number: Driver's License Number: Have you had training and expelience in performing massage service? Yes_ No_ If yes, specify the training and expelience? iployment Background for the past five (5) years (list below starting with most recent employment): DATES EMPLOYERS POSITION HELD