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

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I . . . List your residence addresses for the past five years: ,. (Street Addrus) (Clly) (Stllte) (ZIpC:-) (SIreet AdOrN') (Clly) (Stete) (ZipC_) tStreeIAdd.....) (Clly) ISI.~) (ZipC:-) IS.... ......., (CIly) (SllItII) (ZipC_) (S,,"I AddreN) (CIly) (Slele) (~COd.) List three (3) residents of the seven county Twin Cities metro area, not related to the applicant, that will vouch for your sobriety, honesty, and general good moral character. Submit a written reference letter from each person listed below. (HarM) (StrHt, City, 51U, z.., Code) (PhoMNo.) (Name) (Street, CII:y, Slate, ZIp COOt) (Phone No.) (Name) (S.,..I, City, Stale, Zip CoOe) (PhonIINo.) ppllcants must attach evidence of their education qualifications, Including originals or certified copies of Degrees, Diplomas or ertificates,lf any. Applicants must provide evidence of their practical qualifications to practice massage. I HEREBY UNDERSTAND AND AGREE THAT: 1. INFORMATION REVEALED BY AN APPLICANT FOR AN OCCUPATIONAL LICENSE IN THE CITY OF MINNETONKA WILL BE USED BY THE CITY IN ACCORDANCE WITH FEDERAL AND STATE LAWS REGARDING PRIVACY OF CRIMINAL RECORDS. 2. A CRIMINAL CONVICTION WILL NOT BAR AN APPLICANT FROM OBTAINING A LICENSE WITH THE CITY OF MINNETONKA UNLESS SUCH CONVICTION IS DIRECTLY RELATED TO THE OCCUPATION FOR WHICH THE LICENSE IS SOUGHT, ACCORDING TO MINNESOTA STATUTES 9364.03. 3. HOWEVER, FAILURE TO REVEAL A CRIMINAL CONVICTION WILL BE CONSIDERED FALSIFICATION OF THE APPLICATION AND MAY BE USED AS GROUNDS FOR DENIAL OF THE APPLICATION. I DECLARE THAT THE INFORMATION I HAVE PROVIDED ON THIS APPLICATION IS TRUTHFUL, AND I AUTHORIZE THE CITY OF MINNETONKA TO INVESTIGATE THE INFORMATION AND CONTACT THE PERSONS NAMED ON THE APPLICATION. I HEREBY AGREE TO NOTIFY THE CITY OF ANY CHANGE IN THE INFORMATION PRESENTED HERE WHICH MAY OCCUR DURING THE LICENSE PERIOD. I HEREBY AUTHORIZE THE CITY OF MINNETONKA TO HAVE ACCESS TO ALL SOURCES OF INFORMATION WHICH MAY BE CONSULTED TO VERIFY THE INFORMATION I HAVE PROVIDED ABOVE. THIS INCLUDES AUTHORIZATION TO CHECK CRIMINAL HISTORY RECORDS IF I HAVE BEEN ASKED TO PROVIDE THAT INFORMATION. X (Signaltn of AppIicanI) Subscribed and sworn to before me a Notary Public on this day of ,19_. Commission expires on: (NotllryP\bIIc) _....)