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<br /> " <br />I <br />.- <br />. <br /> List your residence addresses for the past five years: <br />,. <br />. <br />. \5"", AddreN) ICIty) (St.le) (lip"""") <br /> (SIrM-\ AdIna.) ICIty) (51_I (lip"",,") <br /> (StrHt Mdren) ICity) (Slat.) (lip"""") <br /> (SIte.1 AddreP) ICIty) IS....) (lIpC"'1 <br /> (SIt'HI AddreU) (City) (Slate) (lIpCodoI <br /> <br />list three (3) residents ofthe seven county Twin Cities metro area, not related to the applicant, that will vouch for your sobriety, honesty, and <br />general good moral character. Submit a written reference letter from each person listed below. <br /> <br />(N~) <br /> <br />(Street, City, SI.le, ZIp Codel <br /> <br />(P~Ho.) <br /> <br />(......1 <br /> <br />(511.... City, Stahl. Zip Code) <br /> <br />(PhonoNo.1 <br /> <br />(N.....) <br /> <br />(SuN\, City, Stete, Zip COIM) <br /> <br />(PI'lchNo.l <br /> <br />.ppllcants must attach evidence of their education qualifications, including originals or certified copies of Degrees, Diplomas or <br />ertificates, If any. Applicants must prOVide evidence of their practical qualifications to practice massage. <br />I HEREBY UNDERSTAND AND AGREE THAT: <br /> <br />1. INFORMATION REVEALED BY AN APPLICANT FOR AN OCCUPATIONAL LICENSE IN THE CITY OF MINNETONKA WILL BE <br />USED BY THE CITY IN ACCORDANCE WITH FEDERAL AND STATE LAWS REGARDING PRIVACY OF CRIMINAL RECORDS, <br /> <br />2. A CRIMINAL CONVICTION WilL NOT BAR AN APPLICANT FROM OBTAINING A LICENSE WITH THE CITY OF MINNETONKA <br />UNLESS SUCH CONVICTION IS DIRECTLY RELATED TO THE OCCUPATION FOR WHICH THE LICENSE IS SOUGHT, <br />ACCORDING TO MINNESOTA STATUTES 9364.03. <br /> <br />3. HOWEVER, FAILURE TO REVEAL A CRIMINAL CONVICTION Will BE CONSIDERED FALSIFICATION OF THE APPLICATION <br />AND MAY BE USED AS GROUNDS FOR DENIAL OF THE APPLICATION. <br /> <br />I DECLARE THAT THE INFORMATION I HAVE PROVIDED ON THIS APPLICATION IS TRUTHFUL, AND I AUTHORIZE THE CITY OF <br />MINNETONKA TO INVESTIGATE THE INFORMATION AND CONTACT THE PERSONS NAMED ON THE APPLICATION. <br /> <br />I HEREBY AGREE TO NOTIFY THE CITY OF ANY CHANGE IN THE INFORMATION PRESENTED HERE WHICH MAY OCCUR DURING <br />THE LICENSE PERIOD. <br /> <br />I HEREBY AUTHORIZE THE CITY OF MINNETONKA TO HAVE ACCESS TO ALL SOURCES OF INFORMATION WHICH MAY BE <br />CONSULTED TO VERIFY THE INFORMATION I HAVE PROVIDED ABOVE. THIS INCLUDES AUTHORIZATION TO CHECK CRIMINAL <br />HISTORY RECORDS IF I HAVE BEEN ASKED TO PROVIDE THAT INFORMATION. <br /> <br />X <br /> <br />(Splu'eofApptlearttI <br /> <br />Subscribed and sworn to before me a Notary Public <br /> <br />on this <br /> <br />day of <br /> <br />,19_. <br /> <br />Commission expires on: <br /> <br />(NDlaty Pubic) <br /> <br />I <br /> <br />I............) <br />