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<br />MAR-2?-2001 1~:02 <br /> <br />612 985 4499 P.02/04 <br /> <br />.. <br /> <br />CITY OF LAKEVILLE <br />THERAPEUTIC MASSAGE PRACTITIONER <br />LICENSE APPLICATION <br />(Type or Print) <br /> <br />Applicant Name <br /> <br />Firs! <br /> <br />Middle <br /> <br />Last <br /> <br />Home Address <br /> <br />Scree! <br /> <br />City <br /> <br />State <br /> <br />Zip <br /> <br />Telephone Number (includina area cOde) <br /> <br />Dat<: of Birth <br /> <br />I I <br />~-- <br /> <br />How long have you worke4 as a massage practitloner'1 <br /> <br />List placets) of employment in this field for !be past fIVe- (j) years; include addre8se~ and celephoae <br />nwnbe,,: <br /> <br />List your prescnt employer, aderess and telephone number: <br /> <br />Have you been licensed as" massage therapiSt in another municipalIty? Yes_ 1'10_ If yes. <br /> <br />Where <br /> <br />When <br /> <br />Have you ev~r been convicted of any felony, crime or vlolativn cf any citY or<:linance other than rraffle <br />rela:ed? Yes No <br />!fye., piease ~ete the fOllOwing' <br /> <br />nate of aneSl <br /> <br />Municipality of arrest.. <br /> <br />Charge <br />Date of convictloil <br /> <br />Sentence received__ <br /> <br />1111i99 <br />