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<br />NAR-27-21301 10: a3 <br /> <br />612 985 4499 P.04/04 <br /> <br />~ <br /> <br />Pleue reed the following statements cflIl:fully.. By signing below, you agree 10 and are bound by each <br />item. <br /> <br />· I have received from the City of Lal::eville a copy of the Therapeutic Massage Ordinance and will <br />fllllllliarize myself with its provisions. <br /> <br />. r understand that a criminal convlctiOll Willl1O! bar me from oblllining 3 llcense unless the <br />conviction Is directly related to the occupation for w!tich the license is sollght and there is no <br />showlllg of sut!lclent renaoUiUlnOD and presentlltlless III perform the duties of me occupation. I <br />u.ndersWld that faUure to reveal a criminal conviction is falsifICation of the application and <br />constitutes irlllJDds for delllal of the li>:ense. <br /> <br />. The informadon I have provided on this appllcation is trUthful. I authorW: (he City of LakeviUe to <br />investigate the Information and COUW:1 person.s!OlllanizatioDs Damed OD this application. <br /> <br />Signature of Applicant <br /> <br />Subscribed and sworn to before me. a Notary Public, on [his _ day of <br /> <br />Notary Public <br /> <br />Attach aloDg With this applicatioo; <br />(These items will not be returned to the applicant) <br /> <br />1. Eviden>:e of dte :lppiicanr's educatlolUll qualifications, including orieinab or certiried <br />copies of deiIees, diplomas amI certificate from a certified school where this training <br />was received <br /> <br />:2. A recent photograph <br /> <br />3. Copy of birth certificate or naturalization papers <br /> <br />4. Copy of lease for building to hOU$e business (only if renting) <br /> <br />Return completed appiication, along wltll attachments, /0 the City Clerk's office at City <br />Hall, 20195 Holyoke Avenue, between the hOI,Jf$ of 8:00 a.m. and 4;30 p.m., Monday <br />through Friday <br /> <br />TOTAL P. 04 <br />