2002-07-02 P & Z Agenda - Laserfiche WebLink

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. 19. Have you had any previous massage therapist license that W!lS r.evoked, suspended, or not renewed? _____ Yes _____ No If yes, explain in detail: ...----- ------- 20. Have you ever made license or similar __Yes application tor a massage therapist activity and had such application denied? No If yes, explain in detail: ---'" -,----,- ----.- I undQrstand that the infoX'mation provided in this application may 08 considered private or confidential data. I further understand that I may not be. required by law to provide such information. The purpose of providing such information is to aid the city Of Little Canada in its determination on my application for a permit. I acknowledge that providing, or failing to provide, s~ch information may at feet the City'S determination on my application. I understand this information will De maae available to the City Of Little Canada, its city Council. agenda and representatives, as wall as the Minnesota Department of RGVenue, or any other peraon or entity authorized by law to receive said information. I release the City of Little Canada from any and all liability for i-ts l'Gceipt and Use of data received pursuant to this application. --_______, being first ;:11.111' sWox'n, uponhis/haJ: oath, deposes and says that he/she is the person who has executed the above personal Information Form, and that the statements made therein are true of his/tar own knowledge and belie,! . signature SUbscribed and sworn to before me this _____ day of ______ 19_.__,__ . Notary Public cour-,ti- ~Iy commission Expires _ l 11 .; '),ChhQh I CQ 'nM VI<, ~m.j~fi."I"'l ':11 I T 1 J(~ 1 r t t", (;::"I,T Urill ULC"_l'Wl1