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<br />. <br /> <br />. <br />FOR PoweE DEPARTMENT USE '" <br /> <br />. Date of Application: ---1---1_ <br />, Fee: <br /> <br />Reviewed <br />Denied <br />Approved <br /> <br />CITY OF MINNETONKA <br /> <br />PERSONAL SERVICE (MASSAGE) <br />APPlICA TION FOR A NEW LICENSE <br /> <br />This application form requests information which may be classified as private or confidential under the Minnesota <br />Data Practices Act. This infonmation is required by State law or City ordinance. The information will be used to <br />determine your eligibility for issuance of a license, permit, or identification card. Failure to provide the information <br />will result in a denial of the license, permit, or identification card. <br /> <br />Applicanrs Name: Maiden Name: <br />(lalli) (Fr.'l (FultMlddleNams) <br />Residence Address: <br />(StrMI Name) (ClIy) (SIIII.) (Zip"""') <br />Place of Birth: Date of Birth: Phone: <br /> (CIty,Stell) <br />Height: Weight: Color of Hair: Color of Eyes: <br /> <br />Have you ever used an Alias? Yes_ No_ If yes, list name(s), dates and places used: <br /> <br />Marital Status: Married <br />Employer. <br />Employer's address: <br /> <br />Single <br /> <br />Divorced <br />Date of Employment: <br /> <br />Have you been convicted for any crime other than a traffic offense during the past year? Yes_ No_ <br /> <br />If yes, explain: <br /> <br />Have you ever held a Personal Service License in another community? Yes_ No_ If yes, where? <br /> <br />Have you even been denied a Personal Service License in another community? Yes_ No_ If yes, where? <br /> <br />Have you held a Personal Service License in Minnetonka within the last two years? Yes_ No_ <br /> <br />PERSONAL INFORMATION <br /> <br />U.S. Citizen Status: Yes_ No_ If naturalized, date and place: <br /> <br />Social Security Number: Driver's License Number. <br /> <br />Have you had training and experience in performing massage service? Yes_ No_ <br /> <br />If yes, specify the training and experience? <br /> <br />Employment Background for the past five (5) years (list below starting with most recent employment): <br />Q6lli EMPLOYERS POSITION HELD <br />