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<br />MAR-27-2lil01 1:3: a2 <br /> <br />612 98S 4499 P .1a2.'Ql4 <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 />Las! <br /> <br />Home Address <br /> <br />Street <br /> <br />City <br /> <br />Stale <br /> <br />Zip <br /> <br />Telephone Number (ineludlnj: area code) <br /> <br />Date of Birth _1_1_ <br /> <br />How long have you worl<zd as a massage practitioner? <br /> <br />List placets) of employment in this field for the past flVe- (5) years; jJ1(Jude addresses and tel~phone <br />numben: <br /> <br />List your present employer. sdmess and telepllene number: <br /> <br />Have you been licensed as a massage therapist in another municlpahty? Yes_ No_ If yes. <br /> <br />'W'here <br /> <br />When <br /> <br />Have you evel been convicted of any felony, crime or vloiatlon c{ any eil)" otdinance other man traffic <br />rela:ed? Ves No <br />If yes, please eomplete ,the following: <br /> <br />Date of meSI <br /> <br />Municipality of arreSI . <br /> <br />Charge _ <br />Dale of convlc!ioil <br /> <br />Senlfnee reeeived_ <br /> <br />1/11/9& <br />