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<br />" <br />list your residence addresses for the past live years: <br />'I' <br />'. (StreeIAddtNlI (c.,) (S~.) ("'0-' <br /> IStrM Addrel,) (C,>,' (StP} (2<>0-) <br /> (SlnMt A.dlnu) (C>y) (State) (Z;P0-, <br /> (Slrnl AddnIu) (Cilyl (Stale) (Zip 0-) <br /> (StreetAddqu) (cily) (Stale) (Zip 0-) <br /> <br />List three (3) residents ofthe seven county Twin Cities metro area, not related to the applicant, that will vouch for your sobriety. honesty. and <br />general good moral character, Submit a written reference Jetter from each person listed below. <br /> <br />IName) <br /> <br />{Stf8et. CII:y, StalII, ~ CoOel <br /> <br />(PrlcllwND.) <br /> <br />(NlWrle) <br /> <br />(Str8lll, c~. State, ~ CGcle) <br /> <br />(Phone No.) <br /> <br />IN..,.) <br /> <br />CSnet, City, s..... Zip Codel <br /> <br />(PhcnIlNo.) <br /> <br />pplicants must attach evidence of their education qualifications, Including originals or certified copies of Degrees, Diplomas or <br />Certificates, If any. Applicants must provide evidence of their practical qualifications to practice massage. <br />I HEREBY UNDERSTAND AND AGREE THAT: <br /> <br />1, INFORMATION REVEALED BY AN APPLICANT FOR AN OCCUPATIONAL LICENSE IN THE CITY OF MINNETONKA WILL BE <br />USED BY THE CITY IN ACCORDANCE WITH FEDERAL AND STATE LAWS REGARDING PRIVACY OF CRIMINAL RECORDS, <br /> <br />2. A CRIMINAL CONVICTION WILL NOT BAR AN APPLICANT FROM OBTAINING A LICENSE WITH THE CITY OF MINNETONKA <br />UNLESS SUCH CONVICTION IS DIRECTLY RELATED TO THE OCCUPATION FOR WHICH THE LICENSE IS SOUGHT, <br />ACCORDING TO MINNESOTA STATUTES 9364.03. <br /> <br />3. HOWEVER, FAILURE TO REVEAL A CRIMINAL CONVICTION WILL BE CONSIDERED FALSIFICATION OF THE APPLICATION <br />AND MAY BE USED AS GROUNDS FOR DENIAL OF THE APPLICATION. <br /> <br />I DECLARE THAT THE INFORMATION I HAVE PROVIDED ON THIS APPLICATION IS TRUTHFUL. AND I AUTHORIZE THE CITY OF <br />MINNETONKA TO INVESTIGATE THE INFORMATION AND CONTACT THE PERSONS NAMED ON THE APPLICATION. <br /> <br />I HEREBY AGREE TO NOTIFY THE CITY OF ANY CHANGE IN THE INFORMATION PRESENTED HERE WHICH MAY OCCUR DURING <br />THE LICENSE PERIOD. <br /> <br />I HEREBY AUTHORIZE THE CITY OF MINNETONKA TO HAVE ACCESS TO ALL SOURCES OF INFORMATION WHICH MAY BE <br />CONSUL TED TO VERIFY THE INFORMATION I HAVE PROVIDED ABOVE. THIS INCLUDES AUTHORIZATION TO CHECK CRIMINAL <br />HISTORY RECORDS IF I HAVE BEEN ASKED TO PROVIDE THAT INFORMATION. <br /> <br />x <br /> <br />(SiQnaQna(~) <br /> <br />ubscribed and swam to before me a Notary Public <br /> <br />on this <br /> <br />day of <br /> <br />.19_. <br /> <br />Commission expires on: <br /> <br />(N....,.........) <br /> <br />(-<196) <br /> <br />.~, <br />