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<br />MAR-25-01 MON 1.56 PM CIY OF FOREST LAKE <br /> <br />FAX NO. 651 464 4968 <br /> <br />RENEWAL APPLICATION <br />FOR MASSAGE THERAPIST CERTIFICATIONILlCENSE <br />IN THE CITY OF FOREST LAKE <br />ORDINANCE 448 <br /> <br />RENi:lWAL YUR <br /> <br />MASSAGE LOCATION/ADDRESS , <br />HOU~AYSOFOPERATION <br />NAME OF APPLICANT <br /> <br />(lint) <br /> <br />(Jut) <br /> <br />(middle) <br />HOME TELEPIl:ONB #: <br /> <br />DA T8 OF BIRTH <br /> <br />SCHOOL A TIlSNDED AND DECREES RECEIVED: <br /> <br />LIST QUALlFIC... TIONS REQU1IUlD TO PRACTICE MASSAGE: <br /> <br />LIST TWO (2) CHARACTER RllI'llIWNCES WHO kESlDE IN WASHlNOTON COUNTY: NA.\'lES, <br />ADDRESS I: DA TE OF Bl1lTII <br /> <br />HAS APPLICANT EVER l!Ul'I CONVICTED Of A CRIME. OTHER THAN A TRAmC <br />VIOLATION? _YES --..NO <br />IF YES, PLEASE GIVE AN EXPLANAnON ON A SEPARATIl PIECE OF PAPllR, INCLlJ'DING <br />TIME, PLACE ANn NATURE OF SUCH CRIME OR OI'FENSl! AND DISpOsmON THEREOF. <br /> <br />THE APPLICANT SHAw.. PROVIDE THE FOLLOWING INFORMATION: <br /> <br />A. EVIDENCe OF APPLICANTS' EIlUCATIONINCLt.;DlNO CON11l'ItilNO EDUCATION IF <br />APPLICABLE. <br />8. EVIDENCE OP APPLICANTS' QuA!.II'ICAn01liS AND CHAllACTBR REFERB..'ICBS <br />C. EVIDENCE IN nm FOIt.\l: 01' A CURRENT CBRTlFICA'm FROM A LICENSED <br />I'KYSICAN PRACTICING IN MINNIlSOTA lNtllCATlNO THAT SAlD MASSAGE <br />THERAPIST WAS EXAMINED AND IS PRI!.B OF ANY COMMUNICABLE DIS~SE TI,lA T <br />WOL1.D DISQUALIFY THE APPLICA.."IT FROM ENGAGING IN nm Pll..cnC OF <br />MASSAGE. <br /> <br />A RENEWAL CEIlTtF1CATE WILL BE REQUIRED ~CH CALa.'IIlAll YEAR, ALONG WITH A <br />PHYSICAl EXAMINATION cl!.IlTIl'ICA!E, COMPLETl!rl APPLICATION AND Rno'EWA!. FEE <br />OF $~O.Oll. APPUCANTS WILL smen. Y COMPLY WITH ALL REGULATIONS <br />Pll.OMULGA Tl!D SY nm CITY COUNCIL OF FOREST LAX:6 AND ALL ORDINANCES OF SAID <br />MUNIClPLA TV <br /> <br />P .1 <br />. " <br />