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<br />MI'FI-2'7-200119 :i;l2 <br /> <br />612 985 4499 P, 82-"04 <br /> <br />CITY OF LAKEVILLE <br />THERAPEUTIC MASSAGE PRACTITIONER <br />LICENSE APPLICATION <br />(Type or Print) <br /> <br />Applicant Name <br /> <br />First <br /> <br />Middle <br /> <br />Las! <br /> <br />Home Address <br /> <br />Street <br /> <br />City <br /> <br />Stale <br /> <br />Zip <br /> <br />Telephone Number (including w>a ClXle) <br /> <br />Darc of Birth -.-! -.-!_ <br /> <br />How long have you worked u a massage practitlCller'l <br /> <br />Ust p(sce(s) of employment in this field for the past five- ($) years; include sddresses and rekphone <br />nwnbers: <br /> <br />List your presenr employer, ade!ess and telephone number: <br /> <br />Have you been licensed as a massage therapiSt in another municipality' Yes_ ,,"0_ If yes. <br /> <br />Where <br /> <br />When <br /> <br />Have you eVer been convicted of any felony, crime or vIolation cf any city ordinance other than traffic <br />rela:ed? Yes ,'10 <br />If yes, please eornplere:l1e following: <br /> <br />Dale of arreSl Municipality of arrest _ <br /> <br />Charge <br /> <br />Dale of convictio:l <br /> <br />Sentence receive<1_ <br /> <br />1111i~9 <br /> <br />l _ <br />