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<br />MA'<-27-2Il01 18: 02 <br /> <br />612 985 4499 P.02/04 <br /> <br />. <br /> <br />CITY OF LAKEVILLE <br />THERAPEUTIC MASSAGE PRACTITIONER <br />LICENSE APPLICATION <br />(Type or Print) <br /> <br />Applicant Name <br /> <br />First <br /> <br />Middle <br /> <br />~ast <br /> <br />Home Addres. <br /> <br />Street <br /> <br />City <br /> <br />State <br /> <br />Zip <br /> <br />Telephone Number (including area code) <br /> <br />Dati: ofBlrlh _1_1_ <br /> <br />How long have you worked as a massage practitioner? <br /> <br />List p!ace(s) .of employment in this field for the past five. (~) yearS; include addresses and telephone <br />numbers: <br /> <br />List y.our present employer. ader... and relephone number: <br /> <br />Have you been licensed as a massage therapist in another munlcipaltty? Yes_ No_ If yes, <br /> <br />\Vhere <br /> <br />When <br /> <br />Have y.ou ever been convicted of any felony, crime or violation cf any city or<linance oilier than trsffic <br />rela:ed? Yes '10 <br />If ye., please ~ete .the fallowing: <br /> <br />Date of arrest <br /> <br />Municipality of anest <br /> <br />Charge <br />Dale of coovietio;'! <br /> <br />Sentence received <br /> <br />//11/9$ <br />