2002-03-12 P& Z Agenda - Laserfiche WebLink

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, , . 19. Hav~ you had any previous massage therapist license that W~$ revoked, suspended, or not renewed? 'Les __ No Ie yes, explain in detail: .."'----.----.-- --_..,..-~--------- 20, Have you ever made lic~nse or si~ilar __lies application for a massage therapist activity and had such application denied? No It yes, explain in detail: -..-.-....-----,------..- I und~rstand that the information provided in this applioation may be considered private or confidential data. I further un~erstand 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, ~uch information may atrect the City'S determination on my application. I ~nderstand this information will be made available to the city of Little Canada, its City Council, agenda and representatives, as well as the Minnesota Department ot ReVem1e, or any other person or entity authorhed by law to receive said information. I release the city of Little Canada from any and all liability for its receipt and Use of data reoeived pursuant to this application. ---__, being first dUl',' sworn, upon his/her 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/her OWn knowledge and belief. signature SUbsoribed and sworn to before me this _____ day of ______ 19_.____. Notary Public ---.. ....- County My Commission Expire5 !T '" ''''CbMlhICQ '11M VHJ i-l'mn.ll-l"1 ~" T r1 J("1 11 il"\ c::"'" T ~lnll T tLC,'_':JUlI