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<br />1---- <br /> <br />MAR-}R,-O'.' MON,1 'R oM (,TV 'F --REO' 'K'" <br />. ,5, c. V" V 11J" LJI n <br /> <br />FAX NO, 65 J 464 496B <br /> <br />RENEWAL APPLICATION <br />FOR MASSAGE THERAPIST CERTIFICATIONILICENSE <br />IN THE CITY OP FOREST LAKE <br />ORDINANCE 448 <br /> <br />RENEWAL YUR. <br /> <br />MASSAGE LOCATION/ADDRESS <br />HOU~AYSOFOPERAnON <br /> <br />NAME OF AI'PUCANT <br /> <br />(fUll) <br /> <br />(lllldCle) <br />HOME TELEPHONE N: <br /> <br />(lut) <br /> <br />DATE OF BIl\.TH <br /> <br />SCHOOL i\TTENDED AND DEGREES RECEIVED: <br /> <br />LIST QUALlFlCA TIONS REQUIRED TO PRACTICE MASSAGE: <br /> <br />LIST TWO (2) CHARACTER REI'llRSNCES WHO llJlSIDE IN WASHINGTON COlJNTY: NA.'fES, <br />ADDRESS It DA TE OF B1ll.TH <br /> <br />HAS APPLICANT EVER ~ CONVICTED Of A CIUME, OTHER THAN A TRAFFIC <br />VIOLATION? _YES --.NO <br />IF YES, PLEASE GlVE AN EXPLANATION ON A SEPAllATE PlECE OF PAPER. INCLUDING <br />TIME, PLACE AND NATURE OF SUCH CRIME Oil OI'l'ENS! AND DISPOSmON TH!:REOP, <br /> <br />THE APPLICANT SHALJ.. PROVlDS THE 1'0LLOWlNO lNFORMA nON: <br /> <br />A. EVIDENCE OF Al'l'LlC.urrs' EDUCATlONlNCLtJDlNG CONTINUING EDUCATION I:F <br />APPLICABLE. <br />S. EYlDJ:NCE 01' APPLICANTS' QUALIFICATIONS AND CH/t.RACTBR REFERENCBS. <br />C. EVIDJ:NCl! IN TIm FORM OF A CUlIRENT CERTIl'ICAtB FROM A LICBNSBD <br />PHYSICA-N PRACTICING IN MINNESOTA I!IlDICATlNO THAT SAID MASSAGE <br />'!'HEMPlST W AJj EXAMINED AND IS FRBE OF ANY COMMUNICABLE DISUSE THAT <br />WOl)1.D DISQUALIFY THE APPLICAi'lT FROM ENGAGING IN nm PRACTIC OF <br />MASSAGE. <br /> <br />A RENEWAL CERTll'ICATE WILL BE REQUlRSD EACH CALENtlAll YEAR, ALONG WITH A <br />PHYSICAL EXAMINA nON CllRTIFICA TE, COMPLE'Mm APPUCATION AND RENEWAL FEE <br />OF $~o.oo. APPUCANTS WILL smen. y COMPI. Y WITH ALL lUlGULA noNS <br />PROMULGATED BY THIl CITY COUNCIl. OF FOREST LAn AND ALL ORDINANCES Of SAID <br />MlJI'IICIPLA TV <br /> <br />p, 4 <br />